Haven Place Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Haven Place Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF692Sep 3, 2026

  Based on clinical record review and staff interview, it was determined the facility failed to timely respond to significant weight loss for three of eight residents reviewed for nutrition concerns (Residents 1, 5, and 56), implement weight monitoring and continued evaluation for a resident at nutritional risk for one of eight residents reviewed for nutrition concerns (Resident 17), and to obtain, monitor, and evaluate weights, respond to severe weight loss, notify the physician of significant/severe weight loss, and evaluate the effectiveness of nutritional interventions resulting in actual harm of further severe weight loss for one of eight residents reviewed for nutrition concerns (Resident 12). […]

• Actual harm, isolatedF600Dec 19, 2024

  Based on review of select facility policies, facility documentation, clinical record review, and resident and staff interviews, it was determined that the facility failed to protect a resident's right to be free from mental abuse by a staff member for two of three residents reviewed causing actual harm (Residents 1 and 2). Findings include: Review of a Centers for Medicare and Medicaid Services (CMS) Memo S&C: 16-33-NH entitled, Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recording by Nursing Home Staff, dated August 5, 2016, revealed that each resident has the right to be free from all types of abuse, including mental abuse. […]

• No harm, potential for more than minimal, widespreadF812Dec 3, 2021

  Based on observation, staff interview, and review of select facility policies, it was determined that the facility failed to store and prepare food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen, and two of two nursing units (first floor and second floor). Findings include: Review of the facility's policy entitled Long Term Care Resident Food Prepared Outside Facility, last approved March 2021, indicated residents and/or family will be permitted to bring food prepared outside the facility and store the food in the floor stock refrigerator located in the nursing unit pantry. […]

• No harm, potential for more than minimal, patternF628Sep 3, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's representative received written notice of the facility bed-hold policy as soon as practicable for four of five residents reviewed for hospitalizations (Residents 4, 87, 5 and 9). Findings include: Clinical record review for Resident 4 revealed he was transferred to the emergency department for further evaluation after a fall on July 13, 2026. There was no evidence Resident 4's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 4's transfer. Clinical record review for Resident 5 revealed they were transferred to the emergency department for further evaluation of a change in mental status on May 29, 2026. […]

• No harm, potential for more than minimal, patternF744Sep 3, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of five residents reviewed (Residents 4, 11, and 2). Findings include: Clinical record review for Resident 4 revealed the facility admitted him on September 16, 2024, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 4's annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 4, 2026, indicated that the facility assessed Resident 4 as having a diagnosis of dementia, or cognitive loss. […]