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Complaint Investigation

Havencrest Rehabilitation And Healthcare Center

September 30, 2025 · Monongahela, PA · 1277 Country Club Road
Citations 2
CMS Rating 2/5
Beds 48
Provider ID 395633
Healthcare Facility
Havencrest Rehabilitation And Healthcare Center
Monongahela, PA  ·  View full profile →
Inspection Summary

HAVENCREST REHABILITATION AND HEALTHCARE CENTER in MONONGAHELA, PA — inspection on September 30, 2025.

Found 2 citations. 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.

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Inspection Findings

FF0727
Nursing and Physician Services Deficiencies
Potential for More Than Minimal Harm

Based on staff interview and Infection Control Preventionist (ICP) credential review, it was determined that in addition to the role of the Director of Nursing (DON), the DON was also the ICP since 09/08/25.Findings include:

Review of the DON job description indicated the DON is responsible for the planning, organization, development, and direction of the overall operation of the Nursing Department.

The DON is to maintain compliance with federal, state and local regulations.

Review of the Infection Preventionist job description indicated the ICP primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with current federal, state and local standards, guidelines and regulations that govern such programs and as directed by the Administrator to ensure effective infection prevention and control program is maintained at all times.

During an interview on 9/30/25, at 9:08 a.m., the Director of Nursing (DON) stated that the facility just put a Licensed Practical Nurse in place of Infection Control and that she is trained but that she, the Interim DON has been acting as the Infection Control Nurse at this time.

The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who are responsible for implementing programs and activities to prevent and control infections.Pa Code 211.12(b)(c) 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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Havencrest Rehabilitation and Healthcare Center

1277 Country Club Road Monongahela, PA 15063

SUMMARY STATEMENT OF DEFICIENCIES

Based on a review of job descriptions and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.Findings include:

Review of the Infection Preventionist job description indicated the ICP primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with current federal, state and local standards, guidelines and regulations that govern such programs and as directed by the Administrator to ensure effective infection prevention and control program is maintained at all times.

During an interview on 9/30/25, at 9:08 a.m., the Director of Nursing (DON) stated that the facility just put a Licensed Practical Nurse in place of Infection Control and that she is trained but that she, the Interim DON has been acting as the Infection Control Nurse at this time.

The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections. 28 Pa.

Code: 201.14(a) Responsibility of licensee.28 Pa.

Code: 201.18(b)(1)(e)(1) Management.28 Pa.

Code: 201.19(3) Personnel records.28 Pa.

Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Facility ID:

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.


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