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Health Inspection

Elk Haven Nursing Home

May 29, 2026 · Saint Marys, PA · 785 Johnsonburg Road
Citations 3
CMS Rating 5/5
Beds 120
Provider ID 395341
Healthcare Facility
Elk Haven Nursing Home
Saint Marys, PA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

ELK HAVEN NURSING HOME in SAINT MARYS, PA — inspection on May 29, 2026.

Found 3 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.

Inspection Findings

FF0584
Resident Rights Deficiencies

Observation on 5/28/26, at 9:48 a.m. of the resident laundry department revealed one full rack and one partial rack of unmarked resident personal clothing.

During an interview at that time Laundry Aide Employee E3 confirmed: staff do not take unmarked laundry out to the units to enable staff, residents and/or family to identify the owner of the clothing; staff are able to come back to laundry and look for items reported missing by residents/family; family is also able to come back and look through the racks; there is not a process for returning unmarked personal clothing items to residents who are not able to report missing clothing; and once unmarked personal clothing items remain on the racks for a while staff will identify residents in need of a similar size clothing and mark the items for them without first identifying the original owner.

During an interview on 5/28/26, at 10:05 a.m. the Nursing Home Administrator confirmed that if residents and/or family report something missing, they are permitted to look for it within the unmarked clothing; there was not a process in place for resident's/families who cannot report missing clothing items; and that the facility staff do not take the unmarked personal clothing items out to the resident units to attempt to identify the owner of the items. 28 Pa.

Code 201.14 (a) Responsibility of Licensee28 Pa.

Code 201.18 (b)(2)(3)(d) Management28 Pa.

Code 201.29 (a) Resident rights

Based on review of facility policies, observations, and staff interviews it was determined that the

reviewed (B Wing medication room ).

Findings include: Review of facility policy entitled Storage of Medications dated 1/27/26, revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; All such drugs shall be returned to the dispensing pharmacy or destroyed.

Review of manufacturer's guidelines revealed that an open vial of Aplisol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening.

Observation of drug storage on 5/27/26, at 9:55 a.m. of the B Wing medication room revealed an opened vial of Aplisol with an open date of 4/10/26.

During an interview on 5/27/26, at the time of observation, Registered Nurse (RN) Employee E1 confirmed that the open vial of Aplisol had an open date of 4/10/26. RN Employee E1 also confirmed that the vial of Aplisol should have been discarded. 28 Pa.

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

Code 211.9(a)(1) Pharmacy services 28 Pa.

Code 211.12(d)(1) Nursing service 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

395341 05/29/2026

Elk Haven Nursing Home 785 Johnsonburg Road Saint Marys, PA 15857

Review of the Med Pass supplement label revealed After open, consume product within 4 (four) days if properly refrigerated.

Observation on 5/26/26, at 2:20 p.m. in the B wing pantry refrigerator revealed an opened Med Pass supplement dated opened 5/20/26, one cardboard container of thickened water dated opened 5/24/26, with a use by date of 5/21/26, and one cardboard container of thickened water dated opened 5/25/26, with a use by date of 5/21/26.

During an interview at that time Licensed Practical Nurse Employee E2 confirmed that the opened Med Pass was outdated and should have been discarded on 5/24/26 (two days past), and the outdated containers of thickened water should have been discarded on 5/21/26, (five days past). 28 Pa.

Code 201.14(a) Responsibility of licensee 28 Pa.

Code 201.18(b)(1) Management

395341 05/29/2026

Elk Haven Nursing Home 785 Johnsonburg Road Saint Marys, PA 15857

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 SAINT MARYS, 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 ELK HAVEN NURSING HOME or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.