Havencrest Rehabilitation And Healthcare Center
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide an ongoing vital signs and neurological assessment after an unwitnessed fall for three of five residents (Resident Resident R1, Resident R2 and Resident R3). Findings include:Review of the facility policy Managing Falls and Fall Risk dated 4/2/25, indicated all residents experiencing a fall will have an evaluation to identify the root cause of the fall and documentation by the nursing staff should include vital signs and if unwitnessed neuro checks completed. An evaluation of injuries and appropriate first aide if necessary. Staff are to observe for delayed complications for 48 hours and document 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 Resident R1 was admitted to the facility on [DATE REDACTED], with diagnoses which included lung disease, heart fibrillation and dementia.Review of Resident Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/4/25, indicated diagnoses remined current.Review of Resident 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 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 Resident R1 after her fall.Review of the clinical
record indicated that Resident Resident R2 was admitted to the facility on [DATE REDACTED], with diagnoses which included convulsions, schizoaffective disorder, and a history of falls.Review of Resident Resident R2's MDS dated [DATE REDACTED], indicated the diagnoses remained current.Review of Resident Resident R2's care plan initiated on 5/31/24, and updated on 4/25/25, indicated Resident Resident R2 was at risk for falls. Review of a progress noted dated 8/12/25, indicated Resident Resident R2 had and unwitnessed fall with documented vital signs dated 8/5/25. Documentation did not include continued monitoring of Resident Resident R2 after the fall.Review of the clinical record indicated Resident Resident R3 was admitted to the facility on [DATE REDACTED], with diagnoses which included lung disease, urinary infection history and diabetes. Review of Resident Resident R3's MDS dated [DATE REDACTED], indicated the diagnoses remained current.Review of resident Resident R3's care plan initiated on 11/20/24, and updated 7/24/25, indicated Resident Resident R3 was at risk for falls.Review of a progress note dated 7/21/25, indicated Resident 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 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 Resident R1, Resident R2 and Resident 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.
Residents Affected - Some
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
HAVENCREST REHABILITATION AND HEALTHCARE CENTER in MONONGAHELA, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MONONGAHELA, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HAVENCREST REHABILITATION AND HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.