Havenwood Care Center

In the surveyor’s words

From the most serious findings on record at Havenwood Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF803Aug 7, 2025

  Based on interview and document review, the facility failed to ensure a system to provide the correct physician ordered diet texture for 1 of 3 residents (R1) who was at risk for choking and had a history of dysphagia. This resulted in an Immediate Jeopardy (IJ) for R1 when she was provided lunch which was not cut up into bite sized pieces as ordered. As a result, R1 was observed to choke, requiring the Heimlich to clear obstruction, suctioning, and oxygen after she lost consciousness. R1 was transferred to the hospital, was intubated and placed on a ventilator.The IJ began on 7/30/25 at 12:10 p.m., when nursing assistant (NA)-A provided R1 with a lunch tray which included potato chowder with kielbasa pieces and a chicken salad sandwich that were not cut up per physician orders. […]

• Immediate jeopardy, isolatedF760Dec 4, 2023

  Based on interview and document review the facility failed to develop and implement a process to ensure high risk medications were administered and failed to implement a process to report missed doses and/or lack of availability of medications to the provider for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an Immediate Jeopardy (IJ) for R1 when the facility's failure to obtain and administer anti-epileptic medication (used to treat seizures) resulted in increased seizure activity and hospitalization . The IJ began on 11/16/23, when The facility failed to administer three consecutive doses of a high-risk medication to prevent or reduce the risk of seizures resulting in repetitive seizures and hospitalization for R1. […]

• Immediate jeopardy, isolatedF689Oct 6, 2023

  Based on interview and document review, the facility failed to provide adequate supervision when staff did not appropriately respond to a sounding exit door alarm for 1 of 3 residents (R1) identified at risk for elopement, who was able to exit the building, despite wander alert alarming, resulting in R1 being outside the facility without staff knowledge. This resulted in an immediate jeopardy (IJ) for R1. The immediate jeopardy began on 9/23/23, at approximately 6:39 p.m. when R1 was found outside the facility by a visitor walking through the parking lot. The IJ was identified on 10/6/23, and the administrator was notified of the IJ on 10/6/23, at 4:15 p.m. […]

• Immediate jeopardy, isolatedF880Nov 5, 2021

  Based on observation, interview and document review, the facility failed to implement the Centers for Disease Controls (CDC) guidelines for isolation and transmission-based precautions (TBP) with appropriated personal protective equipment (PPE) to prevent the spread of COVID-19; failed to track signs and symptoms of infection for 1 of 1 residents (R1) reviewed who displayed symptoms of COVID-19 and was not placed in isolation with appropriate TBP when symptomatic. This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all residents residing in the facility. […]

• Actual harm, isolatedF689Jan 16, 2026

  Based on observation, interview and document review the facility failed to ensure 1 of 3 residents reviewed for safety from hot liquids was free from burns. This resulted in actual harm to R1 who spilled hot coffee on his lap and sustained a second-degree burn. In addition, the facility failed to implement a system to assess residents for safety with hot liquids.Findings include:R1's Resident Face Sheet indicated he admitted to the facility 7/21/23. R1's diagnosis included dementia, aspiration pneumonia, dysphagia (difficulty swallowing) and insomnia. […]