Pennsylvania Department of Health
HAVEN PLACE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HAVEN PLACE REHABILITATION AND NURSING CENTER
Inspection Results For:

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

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HAVEN PLACE REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Complaint Investigation completed on June 18, 2025, at Haven Place Rehabilitation and Nursing Center, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate to the Health portion of the survey process; however, the facility was not in compliance with 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.

Plan of Correction - To be completed: 07/31/2025

1. The facility cannot retroactively correct the NA ratio; since the staffing citation
2. Facility will conduct an audit consisting of the last two-week period to be sure the facility is in compliance with the nurse aide to resident ratios.
3. Facility will make reasonable attempts to acquire new staff including job fairs, reviewing employee benefits, having assistance from regional recruiter, and looking at employee retention.
4.The NHA/Designee will educate the scheduler/designee on the requirements of meeting the nurse aide to resident ratios.
5. The NHA/Designee will randomly audit the nurse aide to resident ratios weekly x's 6 weeks to ensure regulatory compliance. Any concerns/issues will be reviewed monthly to the facility's QAPI 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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents on the day shift for two of the 21 days reviewed, and one LPN per 30 residents during the evening shift on one of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility for May 25 to 31, 2025, and June 4 17, 2025, revealed the following LPNs scheduled for the resident census:

Day Shift (requires one LPN per 25 residents):

May 27, 2025, 2.5 LPNs for a census of 67, requires 2.68 LPNs

June 15, 2025, 2.5 LPNs for a census of 72, requires 2.88 LPNs

Evening Shift (requires one LPN per 30 residents):

June 14, 2025, 2 LPNs for a census of 72, requires 2.4 LPNs

Interview with the Nursing Home Administrator on June 18, 2025, at 1:00 PM confirmed that the facility did not meet regulatory LPN-to-resident ratios as evidenced above.

Plan of Correction - To be completed: 07/31/2025

1. The facility cannot retroactively correct the LPN ratio; since the staffing citation
2. Facility will conduct an audit consisting of the last two-week period to be sure the facility is in compliance with the LPN to resident ratios.
3. Facility will make reasonable attempts to acquire new staff including job fairs, reviewing employee benefits, having assistance from regional recruiter, and looking at employee retention.
4.The NHA/Designee will educate the scheduler/designee on the requirements of meeting the LPN to resident ratios.
5. The NHA/Designee will randomly audit the LPN to resident ratios weekly x's 6 weeks to ensure regulatory compliance. Any concerns/issues will be reviewed monthly to the facility's QAPI 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 nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, for 4 of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility for May 25 to 31, 2025, and June 4 to 17, 2025, revealed that the facility failed to meet the minimum hours per patient day for the following days:

June 7, 2025, 2.82 hours PPD
June 8, 2025, 3.15 hours PPD
June 14, 2025, 2.77 hours PPD
June 15, 2025, 3.14 hours PPD

The above information was reviewed with the Nursing Home Administrator on June 18, 2025, at 1:00 PM.

Plan of Correction - To be completed: 07/31/2025

1. The facility cannot retroactively correct the daily HPPD's since the staffing citation
2. Facility will conduct an audit consisting of the last two-week period to be sure the facility is in compliance with the HPPD regulation
3. Facility will make reasonable attempts to acquire new staff including job fairs, reviewing employee benefits, having assistance from regional recruiter, and looking at employee retention.
4.The NHA/Designee will educate the scheduler/designee on the requirements of meeting the daily HPPD.
5. The NHA/Designee will randomly audit the daily HPPDs weekly x's 6 weeks to ensure regulatory compliance. Any concerns/issues will be reviewed monthly to the facility's QAPI Committee

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