Pennsylvania Department of Health
HAVEN CONVALESCENT HOME INC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HAVEN CONVALESCENT HOME INC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Follow-up Survey completed on February 28, 2025, it was determined that Haven Convalescent Home Inc. corrected the federal deficiency cited during the survey of December 13, 2024 under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, failed to correct the state deficiencies cited under the requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the minimum Nurse Aide (NA) ratios of one NA per 10 residents on the day shift for two of nine days reviewed (2/16/25 and 2/23/25); failed to meet the minimum NA ratios of one NA per 11 residents on the evening shift for one of nine days reviewed (2/22/25); and failed to meet the minimum NA ratios of one NA per 15 residents on the overnight shift for two of nine days reviewed (2/16/25 and 2/21/25).

Findings include:

Review of facility nursing staffing documents for the time period from 2/15/25, through 2/23/25, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:

2/16/25 census of 88 residents7.84 NAs worked and 8.80 were required
2/23/25 census of 90 residents8.50 NAs worked and 9.00 were required

Review of facility nursing staffing documents for the time period from 2/15/25, through 2/23/25, revealed the following NA staffing shortage for the evening shift where the NA ratios were not met:

2/22/25 census of 90 residents6.66 NAs worked and 8.18 were required

Review of facility nursing staffing documents for the time period from 2/15/25, through 2/23/25, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

2/16/25 census of 88 residents5.00 NAs worked and 5.87 were required
2/21/25 census of 88 residents5.44 NAs worked and 5.87 were required

During a telephone interview on 2/28/25, at 2:44 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.

Plan of Correction - To be completed: 05/05/2025

Facility Staffing Coordinator was reeducated on current Nursing Assistance (NA) staffing ratios according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed. If a Registered Nurse (RN) or Licensed Practical Nurse (LPN) works as a NA a record will be kept to indicate hours worked as a NA.
Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census.
Nursing Supervisors to be in-serviced on staffing worksheets to indicate what discipline an employee worked as.

For the shifts on the dates indicated all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s) or employees.
Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor or Staffing Coordinator. Facility will utilize facility staff and or temporary Staffing Agencies to fill in shifts as needed according to type of nursing service personal that is needed.
Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility Quality Assurance Performance Improvement Committee

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift for one of nine days reviewed (2/22/25); and failed to meet the minimum of one LPN per 30 residents on the evening shift for one of nine days reviewed (2/22/25).

Findings include:

Review of facility nursing staffing documents for the time period from 2/15/25, through 2/23/25, revealed the following LPN staffing shortage for the day shift where the LPN ratios were not met:

2/22/25census of 90 residents3.41 LPNs worked and 3.60 were required

Review of facility nursing staffing documents for the time period from 2/15/25, through 2/23/25, revealed the following LPN staffing shortage for the evening shift where the LPN ratios were not met:

2/22/25census of 113 residents2.70 LPNs worked and 3.00 were required

During a telephone interview on 2/27/25, at 12:45 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratios for the above days and shifts.

Plan of Correction - To be completed: 05/05/2025

Facility Staffing Coordinator was reeducated on current Licensed Practical Nurse (LPN) staffing ratios according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed. If a Registered Nurse (RN) works as an LPN, a worksheet will be kept to show hours worked as an LPN
Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census.
Nursing Supervisors to be in-serviced on staffing worksheets to indicate what discipline an employee worked as.
For the shifts on the dates indicated all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s) or employees.
Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor or Staffing Coordinator. Facility will utilize facility staff and or temporary Staffing Agencies to fill in shifts as needed according to type of nursing service personal that is needed. Records will be kept if an employee works as a different discipline than scheduled.
Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility Quality Assurance Performance Improvement Committee.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the 3.2 minimum number of general nursing care hours for each 24 hour period for one of nine days reviewed (2/23/25).

Findings include:

Review of facility nursing staffing documents for the time period from 2/15/25, through 2/23/25, revealed the following general nursing care hours was below the minimum 3.2 per patient day (PPD) on the following days:

2/23/25 3.12 PPD

During a telephone interview on 2/27/25, at 2:44 p.m. the Nursing Home Administrator confirmed the facility did not meet the 3.2 PPD minimum direct nursing care hours on the above date.

Plan of Correction - To be completed: 05/05/2025

Facility Staffing Coordinator was reeducated on current nursing care hours provided according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed.
Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census.
Nursing Supervisors to be in-serviced on overall nursing hours
For the date indicated all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s) or employees.
Schedule and census will be monitored daily per shift by Registered Nurse (RN) Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor or Staffing Coordinator. Facility will utilize facility staff and or temporary Staffing Agencies to fill in shifts as needed to comply with current nursing care hours in a 24-hour period.
Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility Quality Assurance Performance Improvement Committee

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