Pennsylvania Department of Health
ELK HAVEN NURSING HOME
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ELK HAVEN NURSING HOME
Inspection Results For:

There are 84 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


ELK HAVEN NURSING HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on May 15, 2025, it was determined that Elk Haven Nursing Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Chemical Restraints:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R20).

Findings include:

Review of facility policy entitled "Psychotropic Medication Policy" dated 1/21/25, revealed "the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication."

Review of Resident R20's clinical record revealed an admission date of 3/20/25, with diagnoses that included osteomyelitis (bone infection) of the right ankle and foot, anxiety, and anemia (condition of not enough healthy red blood cells to carry oxygen). The clinical record revealed that on 4/30/25, Resident R20's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.5 milligrams (mg) every 12 hours PRN for anxiety.

Review of Resident R20's May 2025 Medication Administration Record revealed that the PRN Lorazepam was used on 5/4/25, 5/5/25, 5/8/25, and 5/9/25. Resident R20's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the four administrations in May 2025.

During an interview on 5/14/25, at 12:09 p.m. the Director of Nursing confirmed that Resident R20's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/18/2025

1. On 05/27/2025, resident R20's as needed (PRN) lorazepam order updated to include non-pharmacological interventions being attempted and documented in the clinical record prior to administration of medication.

2. On 05/27/2025, all residents with as needed (PRN) psychotropic medications orders will have orders updated to include non-pharmacological interventions attempted and documented in the clinical record prior to medication administration.

3. Education to be provided to nursing staff regarding non-pharmacological interventions attempted and documented in the clinical record prior to medication administration on 06/02/2025 through 06/05/2025.

4. Director of nursing or designee will complete an audit on all residents who receive prn psychoactive medications to ensure non-pharmacological interventions attempted and documented in the clinical record prior to medication administration. Audits will be completed weekly x 4 weeks, monthly x 3 months, and quarterly x 1.

5. Audits will be reviewed at monthly Quality Assurance meetings.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 20 residents reviewed (Residents R10 and R16).

Findings include:

Review of facility policy entitled "Comprehensive Person-Centered Care Planning" dated 1/21/25, indicated "The care plans will be reviewed and revised as necessary by the Interdisciplinary Team at least quarterly after each MDS [Minimum Data Set-a periodic assessment of resident care needs] assessment ..., or more often as changes occur."

Review of Resident R10's clinical record revealed an admission date of 1/3/23, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), gastroesophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones).

Review of Resident R10's physician's orders revealed an order for O2 (oxygen) at 2 LPM (liters per minute) NC (nasal cannula oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) routine and PRN (as needed) dated 3/1/25.

Review of Resident R10's care plan for alteration in cardio and respiratory lacked an intervention for his/her current use of oxygen.

Resident R16's clinical record revealed an admission date of 3/26/19, with diagnoses including Parkinson's disease (a disorder that affects movement related to the central nervous system), major depressive disorder, and moderate intellectual disabilities (limitations to cognitive functioning and skills).

Resident R16's clinical record revealed his/her anticoagulant medication Eliquis (a blood thinning medication that reduces the ability to clot) was discontinued on 2/24/25.

Resident R16's care plan dated 3/7/25, with a target date of 6/1/25, revealed a care plan was in place related to his/her anticoagulant medication Eliquis.

During an interview on 5/14/25, at 1:05 p.m. the Director of Nursing (DON) confirmed that Resident R10's cardio/respiratory care plan was not reviewed/revised to reflect current resident care and services. During an interview on 5/14/25, at 1:45 p.m. the DON confirmed that Resident R16's anticoagulant care plan was not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as necessary.

28 Pa. Code 211.5(f)(ix) Medical records

28 Pa. Code 211.10(c)(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 06/18/2025

1. On 05/15/2025, resident R10's care plan updated to include interventions for current oxygen use.

2. On 05/15/2025, resident R16's care plan updated with the discontinuation of Eliquis on 2/24/2025.

3. All residents receiving anticoagulants and oxygen care plans reviewed to ensure updated.

3. Education to be provided to nursing staff involved in updating care plans on 06/02/2025 regarding reviewing and revising care plans as necessary, and at least quarterly, to reflect current care and services.

4. Director of Nursing or designee will complete an audit of 20% all order changes to ensure comprehensive care plan reviewed and revised as necessary to reflect current care and services weekly x 4 weeks, monthly x 3 months, and quarterly x 1.

5. Audits will be reviewed at monthly Quality Assurance meetings.

Plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provisions of the Federal and State law.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for two of 13 residents reviewed (Residents R27 and R69).

Findings include:

Review of facility policy entitled "Comprehensive Person-Centered Care Planning" dated 1/21/25, indicated "A Baseline Care Plan Summary is provided to the resident and their representative by the completion of the comprehensive care plan."

Review of Resident R27's clinical record revealed an admission date of 10/29/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), diabetes (a health condition that caused by the body's inability to produce enough insulin), and hypertension (high blood pressure).

Resident R27's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R27 and/or his/her representative.

Review of Resident R69's clinical record revealed an admission date of 6/27/24, with diagnoses that included dependence of renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), diabetes, and hypertension.

Resident R69's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R69 and/or his/her representative.

During an interview on 5/14/25 at 1:05 p.m. the Director of Nursing confirmed that the clinical records of Residents R27 and R69 lacked evidence that a written summary of the baseline care plans and order summaries were provided the residents and/or their representatives upon admission to the facility.

28 Pa. Code 211.10(c)(d) Resident care policies

28 Pa. Code 201.18 (b)(1) Management

Plan of Correction - To be completed: 06/18/2025

I hereby acknowledge the CMS 2567-A, issued to ELK HAVEN NURSING HOME for the survey ending 05/15/2025, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement