Health inspection·February 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on a observation and staff interview, it was determined that the facility failed to provide a safe environment for residents in one of two nursing units (Back Hall Nursing Unit). Residents Affected - Some Findings include: During an observation on 2/18/25, at 10:53 a.m. the Utility Room door was noted not to have a locking mechanism. Within the room, a full sharps container without a lid was present on a small table. During an interview on 2/18/25, at 10:58 a.m. Registered Nurse Employee E5 confirmed that the utility room was a Sharps Room, and further confirmed that without a locking mechanism, the full sharps container posed a safety risk to residents. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide a safe environment for residents in one of two nursing units. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 201.29(a)(c)(d) Resident rights. Page 1 of 15 395633 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of three residents (Resident R13 and R26). Residents Affected - Some Findings include: Review of the facility policy, Behavioral Assessment, Intervention and Monitoring dated 3/4/24, indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of the clinical record revealed that Resident R13 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/22/24, included diagnoses of anxiety, depression, bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and post-traumatic stress disorder (PTSD mental health condition triggered by experiencing or witnessing a terrifying event). Review of Resident R20's plan of care developed initiated 5/25/18, and updated 11/22/24, failed to include goals and interventions related to PTSD. Review of Resident R20's evaluations failed to reveal an assessment for trauma-informed care or PTSD. Review of the clinical record revealed that Resident R26 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of anxiety, depression, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and PTSD. Review of Resident R26's plan of care developed initiated 7/10/23, and updated 1/20/25, failed to include goals and interventions related to PTSD. Review of Resident R26's evaluations failed to reveal an assessment for trauma-informed care or PTSD. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing indicated that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of three residents. 28 Pa. Code 211.10 (a) Resident care policies. 395633 Page 2 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0699 28 Pa. Code 211.12(d)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395633 Page 3 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews, it was determined that the facility failed to make certain that medications and biologicals were properly stored and/or disposed of in one of one medication rooms and one of two medication carts (Long Hall medication cart). Findings include: Review of the U.S. FDA approved prescribing information for Aplisol (solution used in tuberculosis screening) dated 11/2013, indicated that in-use vials must be used within 30 days. Review of the U.S. FDA approved prescribing information for Lantus (a type of insulin) dated 05/2019, indicated that in-use vials must be used within 28 days. Review of the U.S. FDA approved prescribing information for Prednisolone Sodium Phosphate (lubricant eye drops) dated 04/2023, indicated that in-use vials must be used within 28 days. Review of the facility policy Medication Storage in the Facility dated 3/4/24, indicated that medication and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. During an observation of the facility's medication room on 2/18/25, at 10:35 a.m. the following was noted: -one opened, undated vial of Aplisol. -four vacutainers with an expiration date of 8/31/24. -four opened sterile dressing kits. -one catheter securement device with an expiration date of 1/28/24. During an interview on 2/18/25, at 10:47 a.m. the above observations were confirmed by Registered Nurse Employee E14. During an observation on 2/18/25, at 11:00 a.m. of the Long Hall medication cart the following was noted: -one Lantus injection pen, partially used and undated. -two bottles of prednisolone 1% suspension eye drops, partially used and undated. -one bottle of Isopto Tears ophthalmic solution 0.5%, partially used and undated. During an interview on 2/18/25, at 11:05 a.m. the above observations were confirmed by Registered Nurse Employee E14. 395633 Page 4 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0761 Level of Harm - Minimal harm or potential for actual harm During an observation on 2/19/25, at 8:15 a.m. the Long Hall medication cart was observed to be unlocked, and unattended by staff. During an interview and observation on 2/19/25, at 8:21 a.m. Registered Nurse Employee E10 returned to the medication cart and confirmed that she had left it unlocked while in a resident room. Residents Affected - Some During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that medications and biologicals were properly disposed of in one of one medication rooms and one of two medication carts. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. 395633 Page 5 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of facility policies, observations and staff interview it was determined that the facility failed to properly store, label and date food products and failed to ensure that chemical sanitation levels were at appropriate levels to sanitize dishware and utensils in the main kitchen which created the potential for food borne illness. Findings Include: Review of the facility policy Food Storage last reviewed 3/4/24, indicated that metal and plastic containers must have a tight fitted lid and be accurately labeled with no scoops inside of any food container. Review of the facility policy Quaternary Ammonium last reviewed on 3/4/24, indicated the use if this solution for sanitation of pots, pans and utensils indicated a standard mixture of 200 PPM for adequate sanitation. During an observation in the Main Kitchen the following was identified: The milk cooler temperature indicated that the temperature in the cooler was 41 degrees, there was no thermometer identified inside the cooler to make certain the milk temperature was accurate. A large plastic clear container indicated as the sugar storage bin had a scoop lying inside the bin. A tray containing 21 bowls of dried cereal was undated. The three compartment sink was full and a check of the sanitizing level at the time in the presence of Dietary Manager (DM) Employee E1 revealed a sanitizer strip that did not indicate sanitizer level adequate to meet the level required of 200 ppm as per the manufacturer's recommendations. During an interview completed on 2/2/18/25, at 9:32 a.m., Dietary Manager Employee E1 confirmed the above observations and that the facility failed to properly store, label, and date food an failed to ensure that chemical sanitation levels at appropriate levels to sanitize dishware and utensils in the main kitchen which created the potential for food borne illness. 28 Pa. Code 201.14(a)Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(c) Dietary services. 395633 Page 6 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, manufacturers' instructions, observation, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during glucometer usage for five of six residents (Residents R90, R92, R95, R11, and R16). Residents Affected - Some Findings Include: Review of the facility policy Blood Sampling - Capillary (Finger Sticks) dated 3/4/24, indicated in the list of equipment and supplies needed was a Disinfected blood glucose meter. The policy further indicated that after usage: Following the manufacturer's instructions, clean and disinfect reusable equipment after each use. Review of the Evencare G3 (glucometer) manufacturer's instructions dated 2016, indicated, The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. During an observation 2/19/25, at 4:04 p.m., Licensed Practical Nurse (LPN) Employee E2 removed the glucometer from the medication cart drawer, did not disinfect the glucometer, and checked the blood sugar level of Resident R90. During an observation 2/19/25, at 4:06 p.m., LPN Employee E2, without disinfecting the glucometer after using it for Resident R90, checked the blood sugar level of Resident R92 During an observation 2/19/25, at 4:09 p.m., LPN Employee E2, without disinfecting the glucometer after using it for Resident R92, checked the blood sugar level of Resident R95 During an observation 2/19/25, at 4:17 p.m., Registered Nurse (RN) Employee E3 removed the glucometer from the medication cart drawer, did not disinfect the glucometer; and checked the blood sugar level of Resident R11. During an observation 2/19/25, at 4:20 p.m., RN Employee E3 replaced the glucometer in the medication cart drawer, without disinfecting it. During an observation 2/20/25, at 7:59 a.m., LPN Employee E4 removed the glucometer in the medication cart drawer, without disinfecting it. Observation showed that the glucometer was visibly soiled, with brown spots on it. LPN Employee E4 checked Resident R16's blood sugar level with the soiled glucometer. During an observation on 2/20/25, at 8:04 a.m., LPN Employee E4 cleaned the glucometer with a disinfecting wipe. Observation at this time showed the soilage was removed. During an interview on 2/20/25, at 8:05 a.m., LPN Employee E4 confirmed that the soilage was not a discoloration, was removed from the glucometer with the wipe, and stated, It's dirt. During an interview on 2/20/25, at 12:06 p.m., Infection Preventionist Employee E14 confirmed that glucometers are required to be cleaned between each resident. 395633 Page 7 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/20/25, at approximately 1:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to prevent the potential for cross-contamination during the use of the glucometer. 28 Pa. Code: §201.14 (a) Responsibility of licensee. Residents Affected - Some 28 Pa. Code: §201.18 (b)(1)(e)(1) Management. 28 Pa. Code: §211.10 (d) Resident care policies. 28 Pa. Code: §211.12 (d)(1)(2)(3)(5) Nursing services. 395633 Page 8 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0941 Level of Harm - Potential for minimal harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of ten staff members (Employee E8 and E9). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the effective communication. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have effective communication in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, failed to have effective communication in-service education between 10/30/23, and 10/30/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on the effective communication. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on effective communication for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395633 Page 9 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0942 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of ten staff members (Employee E7, E9, E11, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on Resident Rights. Nurse Aide (NA) Employee E7 had a hire date of 1/19/23, failed to have Resident Rights in-service education between 1/19/24, and 1/19/25. NA Employee E9 had a hire date of 10/30/21, failed to have Resident Rights in-service education between 10/30/23, and 10/30/24. Registered Nurse Employee E11 had a hire date of 12/2/21, failed to have Resident Rights in-service education between 12/2/23, and 12/2/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have Resident Rights in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on the Resident Rights. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Resident Rights for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395633 Page 10 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Abuse and Neglect Prevention for two of ten staff members (Employee E8 and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on Abuse and Neglect Prevention. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have Abuse and Neglect Prevention in-service education between 9/10/23, and 9/10/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have Abuse and Neglect Prevention in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on Abuse and Neglect Prevention. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Abuse and Neglect Prevention for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395633 Page 11 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for four of ten staff members (Employee E8, E9, E11, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI program. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have QAPI in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, failed to have QAPI in-service education between 10/30/23, and 10/30/24. Registered Nurse Employee E11 had a hire date of 12/2/21, failed to have QAPI in-service education between 12/2/23, and 12/2/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have QAPI in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on the QAPI program. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on the QAPI program for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395633 Page 12 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of ten staff members (Employee E6, E9, E11, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI program. Nurse Aide (NA) Employee E6 had a hire date of 1/19/23, failed to have infection control in-service education between 1/19/24, and 1/19/25. NA Employee E9 had a hire date of 10/30/21, failed to have infection control in-service education between 10/30/23, and 10/30/24. Registered Nurse Employee E11 had a hire date of 12/2/21, failed to have infection control in-service education between 12/2/23, and 12/2/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have infection control in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on the infection control program. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on the infection control program for five of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395633 Page 13 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees E8 and E9). Finding include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, received approximately 6.00 hours of in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, received approximately 3.75 hours of in-service education between 10/30/23, and 10/30/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff did not have documentation of 12 hours of in-service education. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for two of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.20(c) Staff development. 395633 Page 14 of 15 395633 02/20/2025 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0949 Level of Harm - Potential for minimal harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for three of ten staff members (Employee E8, E9, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on behavioral health. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have behavioral health in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, failed to have behavioral health in-service education between 10/30/23, and 10/30/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have behavioral health in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on behavioral health. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on behavioral health for three of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395633 Page 15 of 15