Pennsylvania Department of Health
HAVEN CONVALESCENT HOME INC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 41 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on November 25, 2025, at Haven Convalescent Home, Inc., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #081102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed November 25, 2025, it was determined that Haven Convalescent Home, Inc. was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a one-story, Type II (222), protected, non-combustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain the roofing and construction type of the building, affecting the rated assemblies and structural integrity of two of two building components.

Findings include:

Observation on November 25, 2025, at 10:00 a.m., revealed the first floor west wing/long hall, above the exit door, had a roof leak with water dripping through ceiling tiles.

Interview with the administrator and maintenance supervisor on November 25, 2025, at 10:00 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 12/19/2025

Maintenance sealed the roof by the exit door on west wing / long hall. Maintenance replaced the ceiling tiles.

Maintenance will monitor the ceiling tiles above the exit door on west wing / long that they are no leaks weekly x 1 month.

Staff to notify Administration and Maintenance if they notice any leaks or wet ceiling tiles in the building. Repairs will be made accordingly.

NFPA 101 STANDARD Corridor - Doors:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, the facility failed to maintain corridor doors for one of over twenty doors.

Findings include:

Observation on November 25, 2025, at 9:45 a.m., revealed the first floor resident room 211 door failed to close and latch in the frame.

Interview with the administrator and maintenance supervisor on November 25, 2025, at 9:45 a.m., confirmed the door lacked positive latching at the time of the survey.

Plan of Correction - To be completed: 12/11/2025

Maintenance adjusted the door to resident room 211 to enable it to close and latch to the frame.
Maintenance will do weekly checks on the door to room 211 that it closes and latches to the frame at least weekly x 1 month.
All doors in the building will be checked by maintenance at least monthly that they close and latch positively to the frame.

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