F 0584
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observations, and resident and staff interviews, it was determined that the facility failed to
maintain a clean homelike environment for one of twenty-four residents (Resident R33).
Residents Affected - Few
Findings include:
Observations between 7/26/23, and 7/27/23, revealed Resident R33's arm cradle (a device on a wheelchair
that a person's arm lays on when they cannot move that part of their body) was torn the whole way across
the front with foam filling coming out.
During an interview on 7/27/23, with resident R33 he/she stated that the torn area has been there for a long
time and he/she has asked to have the torn arm cradle fixed several times and that it hasn't changed.
During an interview on 7/27/23, at 1030 a.m. the Director of Nursing confirmed that the arm cradle was
ripped with the foam filling coming out of the front, and that the arm cradle was not appropriate and needed
repaired.
28 Pa. Code 201.18(b)(1) Management
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
Page 1 of 3
Event ID:
395341
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
395341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elk Haven Nursing Home
785 Johnsonburg Road
Saint Marys, PA 15857
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on review of facility policy and clinical records, observations, and staff interview, it was determined
that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine
into a bag) care for one of 20 residents reviewed (Resident R36).
Findings include:
Review of a facility policy entitled, Urinary Catheters, dated 1/13/23, indicated that the collection bag should
be kept off the floor, and covered with a dignity bag.
Review of Resident R36's clinical record revealed an admission date of 8/14/21, with diagnoses including
kidney failure/disease, disorders of the bladder, and artificial opening of the urinary tract. The clinical record
revealed a physician's order for the use of a catheter and to check the catheter every shift for placement
and patency.
Observation on 7/25/23, at 2:15 p.m. revealed that Resident R36 was in bed with his/her urine collection
bag hanging on the side of the bed, uncovered and visible from hallway.
Observations on 7/26/23, at 10:00 a.m. and 1:00 p.m. and on 7/27/23, at 8:30 a.m. revealed that Resident
R36 was seated in his/her Geri-chair and the urine collection bag was hanging on the back lower frame of
the chair, uncovered and resting on the floor.
Interview on 7/27/23, at 8:30 a.m. with Registered Nurse Employee E1 confirmed that Resident R36's urine
collection bag should have a dignity bag on and not be on the floor.
28 Pa. Code 211.12(d)(1)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395341
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
395341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elk Haven Nursing Home
785 Johnsonburg Road
Saint Marys, PA 15857
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on review of facility policy, observations and staff interview, it was determined that the facility failed
to prevent the opportunity for potential unauthorized access of medications on one of six medication carts (
A Wing North).
Findings include:
Review of a facility policy entitled, Medication Administration Control and Security dated 1/31/23, indicated
that all medications are to be secured in a locked medication cart until such time as the medication(s) are
administered to the resident.
Observation on 7/26/23, at 9:44 a.m. revealed that the A Wing North medication cart unsecured and
unattended, and had a medication cup of unidentified pills sitting on top, and the top drawer of the cart was
ajar.
Interview at that time with Registered Nurse Employee E2 confirmed that the cart should have been
secured, drawers closed, and no prepared medications on top when the cart is not in view.
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 services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395341
If continuation sheet
Page 3 of 3
