Pennsylvania Department of Health
LOCK HAVEN REHABILITATION AND SENIOR LIVING
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

LOCK HAVEN REHABILITATION AND SENIOR LIVING
Inspection Results For:

There are 103 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.


LOCK HAVEN REHABILITATION AND SENIOR LIVING - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to six Complaint Investigations completed on November 19, 2025, it was determined that Lock Haven Rehabilitation and Senior Living was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations: Based on observation, facility document review, and resident and staff interview, it was determined that the facility failed to serve all meal ticket items for three of five residents observed (Residents 5, 6, and 7). Findings include: During an interview with Resident 5 on November 19, 2025, at 11:20 AM she stated that she often does not receive the items on her tray that she is supposed to. A review of the resident council meeting summary for October 2025, revealed that concerns regarding tray tickets and actual items on the tray are mismatched. Observation of the lunch meal service for unit 4 on November 19, 2025, at 12:15 PM revealed the following: Employee 2 NA (nurse aide), delivered meal trays to the residents and assisted Residents 6 and 7 in preparing their trays by removing the lids and placing them in front of the resident on a tray table. Review of Resident 5's lunch meal ticket (paper slip provided with tray that indicates diet, items to be received, as well as resident allergies and preferences) revealed that the resident had both bread and margarine listed on her ticket. No bread or margarine was observed on the resident's tray. Concurrent reviews and observations of Resident 6 and 7's lunch meal tickets revealed that Resident 6 should have received cottage cheese on her tray, and Resident 7 should have received a grilled cheese sandwich. These items were not present on either resident's tray. Partway through meal service at 12:30 PM, the surveyor notified Employee 2 of the residents missing lunch service items. At this time Employee 2 called down to the kitchen and requested these items be sent for these individuals. The surveyor discussed the above findings with the Nursing Home Administrator on November 20, 2025, at 3:35 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

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

1) Food service manager will review resident council committee minutes for October and follow up with identified residents with concerns with not receiving items on tray tickets. Food service manager will meet with resident # 5,6,7 to review their requests listed on tray tickets and ensure items have been sent.

2) Food service manager and/or designee will audit meal service to verify that residents have received all items on their meal ticket.

3) Food service manager will provide education to dietary staff on ensuring that residents are receiving all items on their meal ticket.

4) Food service manager will complete random audits of meal deliveries over all 3 meals to ensure that residents are receiving items on their meal tickets. Audits will be completed 3 x week x 4 weeks, then weekly x 2 months. Results of audits will be reviewed at QAPI committee.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations: Based on observation and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on two of four nursing units (Unit 1 and Unit 4, Residents 5 and 10). Findings included: An interview with Resident 5 on November 19, 2025, at 11:20 AM revealed that she was very unhappy with the cleanliness of her bathroom, stating she keeps her own broom and a Swiffer mop, so she can clean the area herself, but she is unable to remove the dirt. Observation of the bathroom revealed there was a lot of brown and gray debris on the floor along all of the baseboards that appeared to be stuck to the floor. The threshold was noted to have a gray strip running the width of the doorway and along this strip on both sides was a layer of dust and debris that appeared to be stuck to the floor. These findings were reviewed during an interview with the Nursing Home Administrator and the Director of Nursing on November 19, 2025, at 3:35 PM. An interview with Resident 10 on November 19, 2025, at 1:23 PM revealed concerns with the cleanliness of the bathroom floor. Concurrent observation of Resident 10's bathroom revealed a gap the resident pointed out between areas of the wall and bathroom floor. Observation revealed a small gap, most noticeably between the floor and wall located behind the commode. Some areas of this gap contained unidentified debris. The above information for Resident 10 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on November 19, 2025, at 3:30 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited deficiency 9/19/25 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

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

1) The bathroom floors of Residents 5 and 10 were deep cleaned, paying particular attention to the baseboard area. Any concerns that need maintenance staff to repair were passed on via work order.

2) All other resident bathrooms were audited by both housekeeping and maintenance for concerns with cleanliness and required repairs.

3) Inservice of all housekeeping staff will be completed by manager on infection prevention/control and cleanliness as it relates to corners and edges in resident bathrooms, identifying, correcting and notifying maintenance of any issues and concerns that the staff cannot rectify during daily cleaning.

4) Housekeeping Manager or designee will audit 10 resident rooms and bathrooms weekly x 4 and then monthly x 3 for cleanliness, notify maintenance of any identified concerns, and report findings to the QAPI Committee.

483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel:

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

§483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii).

Observations: Based on observation, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the main kitchen and on two of four nursing units (Unit 4, Residents 5). Findings include: An Interview with Resident 5 revealed that using plastic utensils to cut food on Styrofoam is awful, and this happens often, especially on the weekends. A review of the resident council meeting summary for October 2025, revealed that concerns regarding tray tickets and actual items on the tray are mismatched, and the Fall/Winter menus had not yet been updated or distributed, despite a launch date of October 1, 2025, as indicated on the September resident council meeting. During an interview with Employee 1, Food Services Director, on November 19, 2025, at 10:20 AM it was confirmed paper products (foam containers and plastic ware) were used to serve resident meals for dinner on Wednesday, November 12, due to not having enough food service staff to operate the dish machine to wash dishes and silverware and complete other duties. Employee 1 stated that this is done any time there is not enough staff to wash the dishes and prepare meals. Review of the food service staff schedule for November 2 to 11, 2025, with Employee 1, on November 19, 2025, at 10:20 AM revealed the following open positions for food service workers on the schedule required to meet the needs of the department: Sunday, November 2, 2025, two morning shifts Monday, November 3, 2025, three morning shifts Tuesday, November 4, 2025, one morning shift, one evening shift Wednesday, November 5, 2025, two morning shifts Thursday, November 6, 2025, three morning shifts Friday, November 7, 2025, one morning shift, one evening shift Saturday, November 8, 2025, three morning shifts and one evening shift Sunday, November 9, 2025, two morning shifts Monday, November 10, two morning shifts Tuesday, November 11, 2025, two morning shifts, and two evening shifts Wednesday, November 12, 2025, two morning shifts, and two evening shifts Thursday, November 13, 2025, two morning shifts, and one evening shift Friday, November 14, 2025, one morning shift, one evening shift Saturday, November 15, 2025, two morning shifts The above concerns regarding the timing of meals, and utilization of paper products due to staffing was reviewed with the Nursing Home Administrator on November 19, 2025, at 3:30 PM. 483.60 (a) Sufficient Dietary Support Personnel Previously cited 9/19/25 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

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

1) Food service director will determine why Styrofoam plates were served during meal on 11/12/25. Facility will implement Fall/Winter menu. Food service director will review resident council meeting from October 2025 and speak to residents who voiced concerns that tray tickets do not match what is being served and corrective action will be taken.

2) The dietary service manager will revise the current schedule to ensure that there is adequate coverage so that meals are being serviced on appropriate dinnerware, menu is followed and residents are receiving items on their tray ticket.

3) Food service director will provide education to dietary staff on serving on appropriate dinnerware, following appropriate menu and serving items based on tray tickets.

4) Food service director will complete random audits of meal service 3 x week x 4 weeks, then weekly x 2 months for breakfast, lunch and supper to ensure that meals are served according to menu, on appropriate dinnerware and that residents are receiving their food items based on their tray tickets.

Regional Dietary Manager will review staffing schedule weekly for adequacy. Any deficiencies identified will be corrected before schedule implementation. Regional Dietary Manager will submit a reviewed schedule to the Nursing Home Administrator weekly for 4 months. Instances of staffing shortages or schedule deviations will be logged on a Schedule Deviation Audit. Results of audits will be reviewed at QAPI committee meeting.

§ 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: 12/12/2025

1. The Administrator and nursing leadership meet daily with the contracted schedulers to review future schedules, troubleshoot areas of concern and discuss possible solutions for any days/shifts that do not meet the required staffing ratios. The leadership team is in constant contact via a secure messaging platform with the scheduling team regarding call offs and the status of filling open shifts. Schedule adjustments will be made as needed via schedule changes, utilizing temporary agency staff, offering bonuses, and utilizing administrative nursing staff. Additional temporary agency staff have been brought on board to meet immediate needs. The HR Director works closely with the corporate recruiters, local CareerLink, local schools and colleges to participate in local job fairs and other recruitment events. Openings are posted via social media and job posting sites. Facility Administration meets weekly to review recent hires, terminations and employee recruitment efforts and plan future recruitment and retention events.

2. The Administrator or designee will audit the daily staffing schedule to ensure there are adequate staffing ratios weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance 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.

§ 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.

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

1.The Administrator and nursing leadership meet daily with the contracted schedulers to review future schedules, troubleshoot areas of concern and discuss possible solutions for any days that do not meet the required nursing PPD. The leadership team is in constant contact via a secure messaging platform with the scheduling team regarding call offs and the status of filling open shifts. Schedule adjustments will be made as needed via schedule changes, utilizing temporary agency staff, offering bonuses, and utilizing administrative nursing staff. Additional temporary agency staff have been brought on board to meet immediate needs. The HR Director works closely with the corporate recruiters, local CareerLink, local schools and colleges to participate in local job fairs and other recruitment events. Openings are posted via social media and job posting sites. Facility Administration meets weekly to review recent hires, terminations and employee recruitment efforts and plan future recruitment and retention events

2.The Administrator or designee will audit the daily staffing schedule to ensure there are adequate staffing ratios weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance Committee.

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