Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Hall Health Care Center during CMS and state inspections, most recent first.
PBJ Report Submitted Incorrectly and Verified After Deadline: The facility failed to ensure the PBJ report was submitted accurately and within the CMS deadline for one quarterly reporting period. The Administrator said the corporate office handled PBJ submissions and she did not have access to confirm timely filing. The Corporate Payroll Rep stated he submitted the report but did not verify the accuracy until after the deadline, when he discovered the wrong information had been filed; records showed the submission time and that successful verification occurred only after the cutoff.
Failure to clarify BP meds before dialysis: A cognitively intact resident on HD was ordered metoprolol and furosemide daily, and staff repeatedly documented the meds as given before dialysis even though the resident said they should be held because they lowered his BP. Multiple LPNs acknowledged either giving the meds or charting them incorrectly, and the DON and MD stated the prescriber should have been contacted to clarify the orders.
Incomplete Perineal Care and Hand Hygiene During Incontinent Care: A CNA changed a resident's brief without providing full peri-care, failed to perform hand hygiene on entry and after touching the bed remote, and applied a clean brief without using peri wipes or soap and water. The DON and RN/IP stated the CNA should have washed hands, removed gloves after touching the remote, and completed peri-care. The resident was dependent for toileting and hygiene and had a hx of UTI, a stage 2 pressure ulcer, local skin infection, quadriplegia, and contractures.
The facility failed to maintain infection control practices when an LPN and RN/IP confirmed oxygen tubing was not bagged or changed as required, a CNA did not perform hand hygiene or complete peri-care before applying a clean brief, and a staff member touched a resident’s food with a bare hand while setting up a meal tray. The residents involved included one who used oxygen as needed, one who was dependent on toileting and hygiene and had a history of UTIs and a pressure ulcer, and one with severe cognitive impairment and malnutrition.
Improper Storage and Replacement of Oxygen Tubing: A resident receiving PRN O2 was observed with tubing that was not bagged and was wrapped around the O2 machine, and the tubing was dated beyond the weekly change interval. An LPN, the DON, and the RN/IP all confirmed the tubing should be bagged and changed weekly per policy; the resident had diagnoses including cerebral palsy and pneumonia and was cognitively intact.
A resident with CHF and dialysis treatment needs was given Metoprolol and Furosemide before dialysis, despite telling nursing staff the meds could lower his BP. Multiple LPNs stated they knew BP meds should not be given before dialysis because of hypotension risk, but they either documented the meds as given when they were held or confirmed they were administered without clarifying the order. The DON and MD stated the provider should have been contacted to clarify the medication plan.
The facility failed to correct their PBJ data before submission to CMS for one quarter in 2024, resulting in a one-star staffing rating and low weekend staffing. The Human Resources Director and Administrator were not directly involved in the PBJ process, which was managed by the corporate office. A glitch in the system used by second or third parties caused discrepancies in the staffing data submitted.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling devices. One resident receiving PEG tube feeding did not have staff wearing gowns during care, despite care plan requirements. Another resident with a nephrostomy drain lacked EBP signage on their door. Staff acknowledged the importance of following care plan guidelines.
The facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) for two residents with indwelling devices. During observations, a CNA and an LPN did not wear gowns while providing catheter and PEG tube care, respectively. The CNA had not received EBP training, while the LPN was uncertain about gown requirements despite prior training. The facility's policy requires gown use for high-contact care to prevent MDRO transmission, as confirmed by the Infection Preventionist and DON.
PBJ Report Submitted Incorrectly and Verified After Deadline
Penalty
Summary
The facility failed to ensure the Payroll-Based Journal (PBJ) report for the October 1 through December 31 reporting period was submitted accurately and within the required CMS timeframe. The facility policy stated that direct care staffing is reported electronically to CMS through the PBJ system and that staffing information is to be reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. During interviews, the Administrator stated that the corporate office handled the PBJ submission process and that she did not have access to ensure timely submission. The Corporate Payroll Representative stated he was solely responsible for submitting the PBJ report and ensuring it was timely. He reported that he submitted the file on day 43, but did not verify the accuracy of the submission until after the deadline had passed, when he discovered the wrong information had been submitted. A review of the email from the corporate compliance office confirmed the report was submitted on Thursday and successfully verified only after the deadline, and the PBJ Final File Validation Report showed a submission time of 4:53 PM on 2/12/26.
Failure to Clarify BP Meds Before Dialysis
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards of practice and physician oversight for a resident receiving dialysis. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including chronic diastolic congestive heart failure. His active medication orders included metoprolol succinate ER 25 mg daily and furosemide 80 mg daily, both scheduled for 8 AM, while his dialysis treatments were scheduled for 11 AM on Mondays, Wednesdays, and Fridays. The resident stated that nursing staff were giving him blood pressure medications before dialysis even though he told them he could not take them because they would lower his BP to an unsafe level. He reported that he had previously held these medications on dialysis days before admission. The MAR showed that metoprolol and furosemide were documented as given before dialysis on multiple dialysis days after admission, including 3/20/26, 3/23/26, 3/25/26, 3/27/26, and 3/30/26. Several LPNs confirmed that they administered or documented the medications before dialysis and stated that they knew BP medications could cause hypotension during dialysis. One LPN said she pulled the medications but held them and accidentally documented them as given; another said she did not give them but forgot to correct the documentation; and another confirmed giving them because there was no order to hold them. The DON stated the provider should have been contacted to obtain a hold order or clarify whether the medications should be given, and the medical director stated that the nurses should have notified him in this resident’s case because the resident had reported that he normally did not take the medications before dialysis due to prior BP drops during treatment.
Incomplete Perineal Care and Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to provide complete perineal care for one resident observed for incontinent care. During an observation, the CNA gathered a gown, gloves, and a brief, knocked on the door, entered the room, donned a gown and gloves, and adjusted the bed remote while wearing gloves. The CNA did not wash hands before putting on gloves, did not remove gloves and perform hand hygiene after touching the remote, and removed the soiled brief and applied a clean brief without providing peri-care using peri wipes or soap and water. During interview, the CNA confirmed she did not completely perform peri-care and stated she changed the brief but forgot to gather supplies for peri-care. She also confirmed she did not perform hand hygiene upon entry, after touching the remote, or before changing the brief. The resident had a history of UTI, a stage 2 pressure ulcer, local skin infection, quadriplegia C1-C4 incomplete, and contractures. The resident's MDS showed a BIMS score of 15 and dependence for toileting and hygiene. The DON and RN/Infection Preventionist stated the CNA should have washed hands, removed gloves after touching the remote, and provided peri-care with soap and water or peri wipes.
Infection control failures with oxygen tubing, peri-care, and food handling
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program based on observations, interviews, and record review involving oxygen tubing, perineal care, and food handling. Facility policies reviewed included respiratory therapy infection prevention guidance requiring oxygen circuits to be stored in a plastic bag marked with the date and resident name between uses and changed every seven days, as well as hand hygiene guidance stating hand hygiene is required before touching a resident, before handling food, and after touching the resident’s environment or belongings. For one resident who used oxygen as needed, surveyors observed the oxygen tubing beside the bed, wrapped around the oxygen machine, not bagged, and dated 3/19/26. Staff interviews confirmed the tubing should have been in a bag and changed weekly, with the DON stating it should have been changed on 3/26/26 and the RN/Infection Preventionist stating it was supposed to be in a bag and changed weekly. The resident’s record showed diagnoses including cerebral palsy and pneumonia, and an order for oxygen 2L/min via nasal cannula as needed to keep oxygen saturation above 92%. For another resident who was dependent on toileting and hygiene and had diagnoses including a history of UTIs, a stage 2 pressure ulcer, local skin infection, and quadriplegia, a CNA was observed performing peri-care incompletely. The CNA entered the room without hand hygiene, touched the bed remote with gloves on without removing the gloves or performing hand hygiene, and then removed the soiled brief and applied a clean brief without providing peri-care with wipes or soap and water. For a third resident with severe cognitive impairment and malnutrition, a staff member placed a lunch tray in front of the resident and used a bare hand to touch and cut the hamburger. The staff member acknowledged touching the food, and the DON and RN/Infection Preventionist stated staff should never touch a resident’s food with bare hands because it is a cross-contamination issue.
Improper Storage and Replacement of Oxygen Tubing
Penalty
Summary
The facility failed to store and replace oxygen tubing in accordance with professional standards and facility policy for one resident receiving oxygen as needed. Facility policy required the oxygen circuit to be stored in a plastic bag marked with the date and resident's name between uses and the administration set to be discarded every seven days. On 03/30/2026, the resident was observed sitting in a wheelchair with oxygen tubing beside the bed; the tubing was not bagged and was wrapped around the oxygen machine, and it was dated 3/19/26. The resident stated he uses oxygen sometimes. An LPN stated the tubing should be in a bag to prevent bacteria from getting on it and confirmed it was not bagged and was dated 3/19/26. The DON stated oxygen tubing is supposed to be changed weekly and should have been changed on 3/26/26, and that it should have been in a bag to keep it off the floor and prevent infection. The RN/Infection Preventionist also stated the tubing is supposed to be in a bag and changed weekly, and confirmed that not changing the oxygen tubing could put the resident at risk for infection. The resident's record showed an order for oxygen 2 L/min via nasal cannula as needed to keep oxygen saturation above 92%, with oxygen saturation checks every shift. The resident had diagnoses including cerebral palsy and pneumonia, and the MDS showed a BIMS score of 14, indicating the resident was cognitively intact.
Inaccurate MAR documentation and failure to clarify dialysis-day blood pressure medications
Penalty
Summary
The facility failed to ensure nursing staff were competent to carry out safe medication administration and clinical decision making for a resident receiving dialysis-related care. The resident was cognitively intact, had diagnoses including chronic diastolic congestive heart failure, and had active orders for Metoprolol Succinate ER 25 mg daily and Furosemide 80 mg daily. The facility policy on administering medications stated that medications are to be given safely and as prescribed, and that if a dosage is believed to be inappropriate or excessive, or if a medication may have adverse consequences, the nurse is to contact the prescriber, attending physician, or medical director. The resident stated that nurses were giving his blood pressure medications before dialysis even though he told them he could not take them because they would lower his blood pressure to an unsafe level. Record review of the MAR showed that Metoprolol 25 mg and Furosemide 80 mg were documented as given at 8 AM before the resident's 11 AM dialysis appointments on multiple dialysis days. During interviews, one LPN stated she had pulled the medications but held them because they could lower blood pressure, yet she documented them as given. Another LPN stated she knew blood pressure medications should not be given before dialysis because of the risk of hypotension, but she also documented them as given and said she forgot to correct the documentation. A third LPN confirmed she gave the medications before dialysis and noted there was no order to hold them. The resident stated he had told nursing staff and the dialysis nurse that he should not take the medications before treatment, and he reported that he took them when they were mixed with his other medications. The dialysis nurse stated the resident had previously held his medications before dialysis because his blood pressure typically drops during treatment. The DON stated the provider should have been called to obtain a hold order or clarify whether the medications should be given, and that nurses should investigate when residents voice concerns about medications. The Medical Director stated that in this resident's case, nurses should have notified the provider to avoid lowering the resident's blood pressure to an unsafe level and avoid complications.
Inaccurate PBJ Data Submission Due to System Glitch
Penalty
Summary
The facility failed to ensure that their Payroll-Based Journal (PBJ) data, which contains staffing hours necessary for the appropriate care of residents, was corrected before submission to the Centers for Medicare and Medicaid Services (CMS) for one of the four quarters in 2024. Specifically, during the third quarter of the fiscal year 2024, the facility's PBJ Staffing Data Report revealed a one-star staffing rating and excessively low weekend staffing, which triggered a concern. The facility's policy requires complete and accurate direct care staffing information to be reported electronically to CMS through the PBJ system in a uniform format specified by CMS. Interviews conducted during the survey revealed a lack of direct involvement from both the Human Resources Director and the Administrator in the PBJ reporting process, as this responsibility was managed by the corporate office. The Corporate Payroll Representative acknowledged receiving daily staffing sheets from the facility and noted a discrepancy between the data extracted from the facility and what was exported to PBJ, due to a glitch in the second or third party's system. This issue led to inaccuracies in the reported staffing data, contributing to the deficiency identified during the survey.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement care plan interventions related to Enhanced Barrier Precautions (EBP) for two residents with indwelling devices. For Resident #25, who receives PEG tube feeding, the care plan required staff to maintain EBP, including wearing a gown during close contact care. However, during an observation, an LPN was seen performing PEG tube site care without wearing a gown. The LPN admitted to being aware of the EBP signage but was uncertain about the gown requirement, despite having received EBP training. The Infection Preventionist confirmed that wearing a gown is necessary for PEG tube care as part of EBP. For Resident #33, who has a nephrostomy drain, the care plan required EBP signage to be placed on the resident's door. Observations revealed that there was no EBP signage on the door. The Infection Preventionist confirmed that signage should be present to protect against infection for residents with indwelling devices. The Director of Nurses and the Care Plan Nurse both acknowledged the importance of following care plan guidelines, emphasizing that staff are expected to adhere to the care plans.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed by staff when providing direct care to residents with indwelling devices. Specifically, two residents, one with a Foley catheter and another with a PEG tube, were not provided care in accordance with the facility's EBP policy. During an observation, two CNAs did not wear gowns while performing catheter care for a resident with urine retention. The CNA involved admitted to not receiving training on EBP and confirmed the omission of gown use. Another observation revealed an LPN performing PEG tube care without a gown, despite being aware of EBP signage. The LPN expressed uncertainty about the requirement to wear a gown, even though she had received EBP training. The facility's policy on Enhanced Barrier Precautions mandates gown and glove use during high-contact care activities for residents at risk of MDRO transmission, such as those with wounds or indwelling devices. The Infection Preventionist confirmed that EBP was instituted in March, with in-services conducted to educate staff. The Director of Nursing acknowledged the requirement for staff to wear gowns during close-contact care to prevent infection transmission and confirmed that the staff involved should have adhered to these guidelines. The deficiency was identified through observations, interviews, and record reviews, highlighting a lapse in adherence to infection control protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brookhaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Brookhaven | 0.9 mi | ★★★★★ | 9 | 0 |
| Trend Health And Rehab Of Brookhaven | 0.9 mi | ★★★★★ | 6 | 0 |
| Silver Cross Health & Rehab | 1.1 mi | ★★★★★ | 11 | 0 |
| Pine Crest Guest Home Inc | 19.5 mi | ★★★★★ | 0 | 0 |
| Lawrence Co Nursing Center | 20 mi | ★★★★★ | 3 | 0 |
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