Havencare at Filosa

In the surveyor’s words

From the most serious findings on record at Havencare at Filosa, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF583Apr 8, 2026

  Based on observation, review of the clinical record, facility documentation, facility policy, and interview, the facility failed to ensure that the residents' personal and confidential medical information was not accessible for 1 of 3 units, The findings include:Upon entrance to the facility for a recertification survey on 4/6/26, the survey team was provided with the resident roster lists for 3 resident units. Review of the 2nd floor unit resident roster list included a list of names of the 23 residents who reside on the unit. The list also included the residents' diagnosis, TBP, medical devices etc. […]

• No harm, potential for more than minimal, patternF880Apr 8, 2026

  Based on observation, review of the clinical record, facility documentation, facility policy, facility assessment and interview the facility failed to maintain infection control standards as follows.a. The facility failed to ensure the line list for residents on transmission based precautions (TBP) and enhanced barrier precautions (EBP) was complete and accurate. b. The facility failed to ensure that the line list for infection outbreaks was complete and accurate.c. The facility failed to ensure that environmental rounds were completed for multiple months in 2025.d. The facility failed to ensure that tracking and statistical data regarding facility infection rates was maintained for July/August/[DATE].e. […]

• No harm, potential for more than minimal, patternF881Apr 8, 2026

  Based on review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure antibiotic use and surveillance tracking was ongoing from July 2025 - September 2025. The findings include:A review of the facility's antibiotic stewardship program was completed on 4/7/26. Infection line lists failed to identify documentation or tracking infections or antibiotic use for any residents of the facility from July 2025 - September 2025. Review of the facility records failed to identify any designated IP from 7/26/25 - 9/28/25.Interview on 4/7/26 at 11:55 AM with the prior DNS identified that she was employed at the facility as the DNS from 2022 until the beginning of July 2025 and began her new job on 7/7/25. […]

• No harm, potential for more than minimal, patternF882Apr 8, 2026

  Based on review of facility documentation, facility policy, and interviews, the facility failed to designate an individual (s) as the infection preventionist (IP) for multiple time periods between 7/26/25 - 9/28/25. The findings include:During entrance conference on 4/6/26 at 8:05 AM as part of an annual recertification survey with the Administrator and DNS, the DNS identified she began working at the facility on 9/2/25 and identified LPN #1 was the facility IP (this is in conflict with the interview with LPN #1 who identified she assumed the role of IP on 9/29/25). The DNS identified she provided oversight to LPN #1 but was not IP certified. Interview with LPN #1 on 4/7/26 at 10:00 AM identified she had been the IP for the facility since 9/29/25. […]

• No harm, potential for more than minimal, patternF692Aug 7, 2024

  Based on interviews, review of the clinical record, and facility policy for 1 of 4 residents (Resident #47) reviewed for nutrition, the facility failed to document the percentage of supplements consumed in regard to significant weight loss. The findings include: Resident #47's diagnoses included left sided hemiplegia and hemiparesis (muscle weakness) following a cerebral infarction, dysphagia, and dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required supervision or touch assistance with eating, partial/moderate assistance with oral hygiene, and was dependent with personal hygiene. Additionally, Resident #47's MDS identified no significant weight loss at that time. […]