Havencrest Rehabilitation And Healthcare Center
HAVENCREST REHABILITATION AND HEALTHCARE CENTER in MONONGAHELA, PA — inspection on August 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the facility Fall care path indicated that vital signs including neuro checks if unwitnessed fall should continue for 24 to 72 hours.
Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included lung disease, heart fibrillation and dementia.Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/4/25, indicated diagnoses remined current.Review of Resident R1's care plan initiated on 5/12/23 and updated 6/9/25, indicated at risk for falls.Review of a progress note indicated Resident R1 had an unwitnessed fall on 6/25/25, with documented vital signs dated 6/4/25.
Documentation did not include continued monitoring of Resident R1 after her fall.
Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included convulsions, schizoaffective disorder, and a history of falls.Review of Resident R2's MDS dated [DATE], indicated the diagnoses remained current.Review of Resident R2's care plan initiated on 5/31/24, and updated on 4/25/25, indicated Resident R2 was at risk for falls.
Review of a progress noted dated 8/12/25, indicated Resident R2 had and unwitnessed fall with documented vital signs dated 8/5/25.
Documentation did not include continued monitoring of Resident R2 after the fall.
Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses which included lung disease, urinary infection history and diabetes.
Review of Resident R3's MDS dated [DATE], indicated the diagnoses remained current.Review of resident R3's care plan initiated on 11/20/24, and updated 7/24/25, indicated Resident R3 was at risk for falls.Review of a progress note dated 7/21/25, indicated Resident R3 had an unwitnessed fall with documented vital signs dated from a previous time of the same date.
Documentation did not include continued monitoring or Resident R3 after the fall.
During an interview on 8/21/25, at 11:02 a.m., the Director of Nursing (DON) confirmed the facility failed to provide an ongoing vital signs and neurological assessment post unwitnessed fall for three of five residents (Resident R1, R2 and R3). 28 Pa.
Code: 201.14(a) Responsibility of licensee.28 Pa.
Code: 201.18 (b)(1) Management.28 Pa.
Code: 211.10 (c)(d) Resident Care policies.28 Pa.
Code: 211.12 (d)(1)(2)(3)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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