Safe Haven Adult Care Home

The facility failed to ensure a Licensed Health Professional Support (LHPS) evaluation was completed quarterly for one resident who required fingerstick blood sugar checks. Documentation for the required quarterly assessments was missing from the resident's record during the survey.

The facility failed to ensure a Licensed Health Professional Support (LHPS) evaluation was completed quarterly for a resident requiring fingerstick blood sugar (FSBS) checks. While blood sugar checks were being documented in the MAR, the last required LHPS evaluation for this resident was not completed since September 11, 2024.

The facility failed to ensure that one of three sampled residents had a completed care plan within 30 days of admission. Specifically, Resident #2, who was admitted on 11/21/24, did not have a care plan available for review. The Administrator admitted to not auditing resident records since May 2024, which led to this oversight.

The facility failed to ensure that one of three sampled residents had a completed care plan within 30 days of admission. Specifically, Resident #2, who was admitted on 11/21/23, did not have a care plan available for review.

The facility failed to ensure a Licensed Health Professional Support (LHPS) evaluation was completed quarterly for one resident who required fingerstick blood sugar (FSBS) checks. The facility did not meet the requirement for quarterly evaluation of the resident's health status and care provided.

The facility failed to ensure medication was available and administered as ordered for one resident. Specifically, there was no documentation of the prescribed tramadol 50 mg being administered three times a day, and pharmacy records indicated the medication had not been dispensed since February 2023.

The facility failed to ensure that medication was available and administered as ordered for one resident. Specifically, there was an order for Tramadol 50 mg three times daily, but there was no documentation of the medication being administered between 08/14/23 and 08/23/23.

The facility failed to properly notify the Division of Facility Services regarding a change in the overall evacuation capability of a resident. Specifically, Resident #3's assessment indicated a need for a cane and wheelchair for long distances due to arthritis and edema, which impacts the documented evacuation capability.

The facility failed to ensure medication administration records (MARs) were accurate for a resident. Specifically, the MAR contained outdated instructions for a weekly high-dose vitamin D supplement and failed to include the new physician order for a daily low-dose vitamin D3 supplement.