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Inspection visit

Health inspection

HAVENCREST REHABILITATION AND HEALTHCARE CENTERCMS #3956332 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. 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 (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395633 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 395633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. 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. Event ID: Facility ID: 395633 If continuation sheet Page 2 of 2

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Citations

2 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0727GeneralS&S Epotential for harm

    F727 - Except when waived under paragraph (f) or (g) of this section, the

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  • 0882GeneralS&S Epotential for harm

    F882 - Infection preventionist

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

FAQ · About this visit

Common questions about this visit

What happened during the September 30, 2025 survey of HAVENCREST REHABILITATION AND HEALTHCARE CENTER?

This was a inspection survey of HAVENCREST REHABILITATION AND HEALTHCARE CENTER on September 30, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HAVENCREST REHABILITATION AND HEALTHCARE CENTER on September 30, 2025?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full tim..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.