Health inspection·April 17, 2025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's current body weight was 101.6 pounds with a BMI (body mass index, a calculation used to estimate a person's body fat percentage based on their weight and height) of 16.9, noting Resident 1 was underweight. Employee 2 indicated Resident 1's IBW (ideal body weight, weight associated with the lowest risk of mortality for a given height and body frame) should be 125 pounds. Resident 1 showed a 4.5 percent weight loss in the last month, a 7.9 percent weight loss in the last three months, and no significant change in the past six months. Resident 1's current diet was full liquids and pureed foods for pleasure. Employee 2 noted Resident 1's meal intake per nursing documentation was less than 25 percent. Resident 1 received Boost VHC (very high calorie, a nutritional supplement) 60 ml (milliliters) BID (twice daily), Ensure clear (a nutritional supplement) QD (daily), Ensure plus (a nutritional supplement) BID, and house shakes (a nutritional supplement). Employee 2 reviewed Resident 1's MAR (medication administration record, a form to document medication administration) and noted they accepted Ensure clear with varying acceptance of the other supplement. Resident 1 needs fed by staff and had no skin issues noted. Employee 2 estimated Resident 1's dietary intake needs as: 1385-1615 kcal (kilocalories, a unit of energy commonly used to measure the energy content of food), 50-60 grams protein, and 1 ml/kcal (energy density of a liquid) of fluids. Resident 1 had multiple interventions in place. Employee 2 would discuss advanced directives (i.e., the potential for artificial hydration, alternate way to provide nutritional needs) with the IDT (interdisciplinary team, a group of professionals from different disciplines who work together for a common goal). There was no evidence Employee 2 discussed anything with the IDT regarding advanced directives. There was no evidence that Employee 2 changed the supplements (i.e., if the resident is accepting of one supplement you would offer the one she was drinking more). Employee 2 could have adjusted them for a potential help for the weight loss. Review of a facility grievance form dated April 13, 2025, revealed Resident 1's responsible party voiced concerns with Resident 1 not receiving Ensure on their tray. Nursing documentation dated April 14, 2025, at 2:24 PM revealed the Director of Nursing (DON) spoke with Resident 1's responsible party regarding the concern noted above. The DON spoke with Employee 3, registered dietician, regarding Resident 1's responsible party's Ensure concerns with a house mighty shake (a nutritional supplement) being substituted. Employee 3 indicated the nutritional supplement substitution was satisfactory. The DON noted that Ensure clear was being provided on Resident 1's tray. Dietary was contacted and confirmed that they did have Ensure and mighty shakes available and provided Ensure on Resident 1's tray. The DON spoke with the facility's certified registered nurse practitioner (CRNP) regarding Resident 1's weight loss. The CRNP indicated that Resident 1's responsible party was offered hospice in the past but refused, stating they were not ready. There was no documentation that Employee 2 increased, changed, or implemented new dietary nutritional supplements to potentially mitigate Resident 1's weight loss or increase their meal intakes when identified on March 11, 2025. There was no documentation that Employee 2 or 3 reviewed, assessed, monitored, or implemented further dietary interventions for Resident 1's continued weight loss after March 11, 2025. Interview with the Nursing Home Administrator (NHA) on April 17, 2025, at 1:30 PM revealed that Employee 2, was the dietician who covered the facility remotely until Employee 3 was hired on March 24, 2025. The NHA confirmed that Employee 3 worked remotely and was not scheduled to visit until April 30, 2025, per Employee 3's schedule. The NHA acknowledged Resident 1's weight concerns and confirmed that Employee 3 had not reviewed Resident 1's clinical record for their weight loss concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haven Place Rehabilitation and Nursing Center 24 Cree Drive Lock Haven, PA 17745 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 28 Pa. Code 211.10(a) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395031 If continuation sheet Page 3 of 3