Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Havencrest Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, muscle weakness, syncope, cognitive communication deficits, non-ambulatory status, unsteady gait, and a history of falls was sent alone to a cardiology appointment despite facility policy requiring staff accompaniment for cognitively impaired residents needing ADL assistance. The resident’s confusion and dependence on staff were documented in clinical and psychiatric evaluations, yet no staff member accompanied the resident to the outside appointment, and the cardiology office reported the resident could not be seen due to confusion. The DON confirmed the resident was sent without needed staff assistance, resulting in a failure to provide appropriate treatment and care according to orders, preferences, and goals.
The facility failed to fully investigate an incident in which a resident with multiple chronic conditions was left on a bedpan for about two hours after being placed there by an LPN during an understaffed overnight shift. The LPN reported asking an NA to monitor the call light and remove the bedpan, but later could not locate the NA when rounds began, and the resident was found still on the bedpan by the LPN and an RN, with no injuries noted. The NA stated she stayed past her shift but was unaware the resident had been placed on a bedpan. The facility’s abuse/neglect investigation policy required interviews with the reporter and other residents cared for by the involved staff, but the DON and NHA acknowledged there was no written proof that such resident interviews or a complete investigation were conducted.
The facility did not have a qualified individual designated as the Infection Control Preventionist (ICP), with the DON performing both the DON and ICP roles. Although an LPN was recently assigned to infection control, the interim DON continued to act as the ICP, resulting in noncompliance with requirements for infection prevention and control program oversight.
The facility did not have a qualified individual officially designated and onsite to manage the infection prevention and control program, as required. Although an LPN was recently assigned to infection control, the Interim DON had been fulfilling the role at the time of the survey, and this was confirmed by the DON during staff interviews.
The facility failed to properly store, label, and date food products and did not ensure adequate chemical sanitation levels in the main kitchen, creating the potential for foodborne illness. Observations revealed issues such as an unverified milk cooler temperature, a scoop inside a sugar container, undated cereal bowls, and inadequate sanitizer levels in the three-compartment sink.
The facility failed to ensure a safe environment in the Back Hall Nursing Unit by not securing the Utility Room, which contained a full sharps container without a lid. This was confirmed by an RN and further acknowledged by the Nursing Home Administrator and the DON.
The facility failed to provide culturally competent, trauma-informed care for two residents with PTSD, as their care plans lacked goals and interventions related to their condition. Additionally, there were no assessments for trauma-informed care in their evaluations. This deficiency was acknowledged by the Nursing Home Administrator and the DON.
The facility failed to properly store and dispose of medications and biologicals, as evidenced by undated and expired items found in the medication room and on the Long Hall medication cart. Additionally, the medication cart was left unlocked and unattended. These deficiencies were confirmed by staff and acknowledged by the Nursing Home Administrator and the DON.
The facility failed to disinfect a glucometer between uses on multiple residents, as required by policy and manufacturer instructions. Staff members, including an LPN and an RN, used the glucometer on several residents without cleaning it, and it was observed to be visibly soiled at one point. Interviews confirmed the non-compliance with disinfection protocols, posing a risk of cross-contamination.
The facility did not provide required Abuse and Neglect Prevention training for two staff members, a Nurse Aide and a Therapy Employee, as per the facility's policy. This deficiency was confirmed by the Assistant Business Office Manager and the Nursing Home Administrator.
The facility failed to provide mandatory infection control training for four staff members, as required by its infection prevention and control program. Documentation showed that a nurse aide, a registered nurse, and a therapy employee did not receive the necessary in-service education within the specified time frames. This was confirmed by the Assistant Business Office Manager, the Nursing Home Administrator, and the DON.
The facility failed to provide the required 12 hours of in-service education for two nurse aides within 12 months of their hire date anniversary. Employee E8 received only 6 hours, and Employee E9 received 3.75 hours of training. This deficiency was confirmed by the Assistant Business Office Manager and the Nursing Home Administrator.
The facility failed to provide training on Resident Rights for four staff members, as required by policy. Documentation showed that a Nurse Aide, a Registered Nurse, and a Therapy Employee did not receive the necessary training within the specified time frames after their hire dates. This was confirmed by interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the DON.
The facility failed to provide effective communication training for two staff members, NA Employee E8 and NA Employee E9, as required by the facility's Staff Development Program policy. This deficiency was confirmed through a review of training records and interviews with facility management.
The facility did not provide mandatory QAPI training to four staff members, as required by their Staff Development Program policy. Documentation showed that a NA, an RN, and a therapy employee did not receive QAPI in-service education within the specified time frames after their hire dates. This was confirmed by the Assistant Business Office Manager, the Nursing Home Administrator, and the DON.
The facility failed to provide required behavioral health training for three staff members, as per the facility's Staff Development Program policy. Documentation showed that a Nurse Aide and a Therapy Employee did not receive behavioral health in-service education within the specified timeframes. Interviews confirmed the absence of documented training, violating state codes on staff development and management.
Failure to Accompany Cognitively Impaired Resident to Cardiology Appointment
Penalty
Summary
The facility failed to provide appropriate treatment and care by not following its own policy for accompanying residents to outside medical appointments. The facility’s Transportation, Resident Appointments policy stated that a member of the nursing staff or Social Services would accompany a resident to an appointment when the resident could not go alone due to factors such as elopement risk, poor judgment, wandering behaviors, cognitive impairment, or need for assistance with ADLs. Resident R33’s clinical record showed diagnoses of dementia, Alzheimer’s disease, muscle weakness, and syncope, with a Minimum Data Set indicating ongoing cognitive impairment and dependence on staff for ADLs. A psychiatric evaluation further documented confusion, memory impairment, cognitive communication deficit, non-ambulatory status, muscle weakness, unsteady gait, and a history of falling. Despite these documented conditions that met the facility’s criteria for requiring staff accompaniment, the Appointment Calendar showed that Resident R33 was sent alone to a cardiology appointment on 1/28/26 at 7:30 a.m. A nurse progress note later recorded that staff from the cardiologist’s office reported the resident needed staff sent with her due to confusion and could not be seen. In an interview, the Director of Nursing confirmed that the resident was sent to the cardiology appointment without facility staff assistance and that the facility failed to provide needed care and services during the transfer to the outside appointment.
Failure to Fully Investigate Incident Involving Prolonged Time on Bedpan
Penalty
Summary
The facility failed to fully investigate a potential incident of abuse or neglect involving one resident, as required by its Abuse Investigation and Reporting policy. The policy, reviewed on 10/8/25, required that all reports of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin be promptly reported and thoroughly investigated, including interviewing the person reporting the incident and other residents who received care from the accused employee. The resident involved, who had diagnoses including high blood pressure, depression, and chronic pain, was re-admitted to the facility on an unspecified date. Facility records showed that on 1/1/26, the resident was placed on a bedpan by an LPN, who then asked an NA to watch for the call light and remove the bedpan. The NA’s shift ended at 4:00 a.m., and during subsequent rounds the LPN and an RN found the resident still on the bedpan, approximately two hours later; no injuries were noted on assessment. During interviews, the DON acknowledged there was no written proof that residents were interviewed about the care and services they received on the night shift when the incident occurred. The NA stated she was asked to stay past her shift, which ended at 3:00 a.m., and that she remained until 3:30 a.m., but reported she was unaware the resident had been placed on a bedpan. The LPN reported that a major snowstorm had caused multiple call-offs, leaving only an RN, the LPN, and one NA to cover the overnight shift, and that she and the RN assisted the NA with resident care, including placing the resident on the bedpan. The LPN also stated she could not locate the NA at 4:00 a.m. when rounds began and described prior derogatory remarks from the NA that led to hard feelings between them. An attempt to interview the RN by telephone was unsuccessful. The Nursing Home Administrator confirmed that the incident involving the resident was not fully investigated and that resident statements regarding their care by staff during the night shift were not obtained, in violation of 28 Pa. Code 201.149(a) and 201.18(e)(1).
Failure to Designate Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to serve as the Infection Control Preventionist (ICP), as required by regulations. The Director of Nursing (DON) was also acting as the ICP since September 8, 2025, in addition to her primary responsibilities. Review of job descriptions confirmed that the DON is responsible for the overall operation of the Nursing Department, while the ICP is tasked with planning and directing the infection control program. During staff interviews, it was confirmed that although a Licensed Practical Nurse (LPN) had recently been put in place for infection control, the interim DON continued to act as the Infection Control Nurse at the time of the survey. This resulted in the facility not having a designated, qualified individual responsible for implementing infection prevention and control programs and activities.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing the infection prevention and control program. Review of the Infection Preventionist job description showed that the role requires planning, organizing, developing, coordinating, and directing the infection control program in accordance with federal, state, and local regulations. During staff interviews, it was revealed that a Licensed Practical Nurse was recently assigned to infection control, but the Interim DON had been acting as the Infection Control Nurse at the time of the survey. The DON confirmed that there was no qualified individual officially designated and present onsite to oversee infection prevention and control activities, as required by regulations.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its own policies regarding food storage and sanitation, which created the potential for foodborne illness. During an observation in the main kitchen, it was noted that the milk cooler's temperature was recorded at 41 degrees, but there was no thermometer inside the cooler to verify the accuracy of the milk's temperature. Additionally, a large plastic container used for sugar storage had a scoop lying inside, contrary to the facility's policy that requires containers to have tight-fitting lids and no scoops inside. Furthermore, a tray containing 21 bowls of dried cereal was found undated, which is against the facility's labeling and dating requirements. The facility also failed to maintain appropriate chemical sanitation levels for dishware and utensils. The three-compartment sink was checked in the presence of the Dietary Manager, Employee E1, and it was found that the sanitizer strip did not indicate a sanitizer level adequate to meet the required 200 ppm as per the manufacturer's recommendations. These observations were confirmed by the Dietary Manager, highlighting the facility's failure to properly store, label, and date food, as well as to ensure that chemical sanitation levels were adequate, thereby creating the potential for foodborne illness.
Failure to Secure Sharps Container in Utility Room
Penalty
Summary
The facility failed to provide a safe environment for residents in the Back Hall Nursing Unit. During an observation, it was noted that the Utility Room door lacked a locking mechanism, and within the room, a full sharps container without a lid was present on a small table. This situation was confirmed by Registered Nurse Employee E5, who acknowledged that the utility room was designated as a Sharps Room and that the unsecured sharps container posed a safety risk to residents. Further confirmation of the facility's failure to maintain a safe environment was provided by the Nursing Home Administrator and the Director of Nursing during an interview.
Failure to Provide Culturally Competent, Trauma-Informed Care
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for two residents, as required by professional standards of practice. Resident R13, who has diagnoses including anxiety, depression, bipolar disorder, and PTSD, did not have goals and interventions related to PTSD included in their plan of care. Additionally, there was no assessment for trauma-informed care or PTSD in Resident R13's evaluations. Similarly, Resident R26, diagnosed with anxiety, depression, schizophrenia, and PTSD, also lacked goals and interventions related to PTSD in their plan of care, and their evaluations did not reveal an assessment for trauma-informed care or PTSD. During an interview, the Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to provide culturally competent, trauma-informed care for these residents. This deficiency was identified through a review of the facility's policy, clinical records, and staff interviews, indicating a lack of adherence to the facility's policy on behavioral assessment, intervention, and monitoring, which aims to maintain the highest practicable physical, mental, and psychosocial well-being of residents.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and disposed of, as evidenced by observations in the medication room and on the Long Hall medication cart. During an inspection, an opened and undated vial of Aplisol was found in the medication room, along with vacutainers and a catheter securement device that were past their expiration dates. Additionally, opened sterile dressing kits were observed. These findings were confirmed by a registered nurse during the inspection. Further observations revealed that the Long Hall medication cart contained a partially used and undated Lantus injection pen, two bottles of prednisolone 1% suspension eye drops, and a bottle of Isopto Tears ophthalmic solution, all of which were partially used and undated. The medication cart was also found unlocked and unattended, which was confirmed by a registered nurse who admitted to leaving it unsecured while attending to a resident. The Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to properly store and dispose of medications and biologicals.
Failure to Disinfect Glucometer Between Uses
Penalty
Summary
The facility failed to prevent potential cross-contamination during glucometer usage for five of six residents. The facility policy required that glucometers be disinfected after each use, as per the manufacturer's instructions. However, observations revealed that staff members, including an LPN and an RN, did not disinfect the glucometer between uses on different residents. Specifically, the glucometer was used on multiple residents consecutively without disinfection, and at one point, it was visibly soiled with brown spots before being used on another resident. Interviews with staff confirmed the failure to adhere to the disinfection protocol. The Infection Preventionist and the Nursing Home Administrator acknowledged that glucometers should be cleaned between each resident to prevent cross-contamination. The report highlights that the facility did not comply with its own policies and the manufacturer's instructions, leading to a potential risk of cross-contamination among residents.
Failure to Provide Abuse and Neglect Prevention Training
Penalty
Summary
The facility failed to provide mandatory training on Abuse and Neglect Prevention for two staff members, Employee E8 and Employee E12. According to the facility's policy, all personnel are required to participate in initial orientation and regularly scheduled in-service training classes. However, a review of the facility's documents and training records revealed that Nurse Aide Employee E8, hired on 9/10/88, did not receive the required training between 9/10/23 and 9/10/24. Similarly, Therapy Employee E12, hired on 10/10/16, lacked documented training within the period from 10/10/23 to 10/10/24. This deficiency was confirmed during interviews with the Assistant Business Office Manager and the Nursing Home Administrator, along with the Director of Nursing, who acknowledged the oversight in training these staff members.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training as part of its infection prevention and control program for four out of ten staff members. The facility policy requires all personnel to participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E6, Nurse Aide Employee E9, Registered Nurse Employee E11, and Therapy Employee E12 did not receive the required infection control in-service education within the specified time frames after their hire dates. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Inadequate In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of in-service education within 12 months of their hire date anniversary for two nurse aides, Employees E8 and E9. According to the facility's Staff Development Program policy, all personnel must participate in initial orientation and regularly scheduled in-service training classes. However, Employee E8, hired on 9/10/88, received only 6 hours of in-service education between 9/10/23 and 9/10/24. Similarly, Employee E9, hired on 10/30/21, received only 3.75 hours of in-service education between 10/30/23 and 10/30/24. This deficiency was confirmed during interviews with the Assistant Business Office Manager and the Nursing Home Administrator, who acknowledged the lack of documentation for the required training hours.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide training on Resident Rights for four out of ten staff members, as determined by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on March 4, 2024, mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E7, Nurse Aide Employee E9, Registered Nurse Employee E11, and Therapy Employee E12 did not have documented training on Resident Rights within the specified time frames after their hire dates. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication for two of ten staff members, specifically Nurse Aide (NA) Employee E8 and NA Employee E9. According to the facility's Staff Development Program policy, all personnel are required to participate in initial orientation and regularly scheduled in-service training classes. However, a review of the facility's documents and training records revealed that NA Employee E8, hired on 9/10/88, did not receive effective communication in-service education between 9/10/23 and 9/10/24. Similarly, NA Employee E9, hired on 10/30/21, lacked documented training on effective communication between 10/30/23 and 10/30/24. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for four out of ten staff members, as required by their Staff Development Program policy. The policy mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E8, Nurse Aide Employee E9, Registered Nurse Employee E11, and Therapy Employee E12 did not receive QAPI in-service education within the specified time frames after their respective hire dates. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training for three out of ten staff members, as determined by a review of facility policy, personnel in-service training records, and staff interviews. The facility's Staff Development Program policy, last reviewed on March 4, 2024, mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E8, hired on September 10, 1988, did not receive behavioral health in-service education between September 10, 2023, and September 10, 2024. Similarly, Nurse Aide Employee E9, hired on October 30, 2021, and Therapy Employee E12, hired on October 10, 2016, also lacked documented behavioral health training within their respective timeframes. Interviews conducted on February 20, 2025, with the Assistant Business Office Manager and later with the Nursing Home Administrator and the Director of Nursing confirmed the absence of documented behavioral health training for these staff members. This deficiency is in violation of 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(c) Staff development.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monongahela
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mon Valley Care Center | 0.9 mi | — | 5 | 0 |
| Rehabilitation Center At Jefferson Hills, The | 10.3 mi | — | 11 | 0 |
| Meadowcrest Rehabilitation & Healthcare Center | 10.6 mi | — | 28 | 1 |
| Southwestern Nursing And Rehabilitation Center | 10.8 mi | — | 0 | 0 |
| John J Kane Regional Center-mc | 12.2 mi | — | 3 | 1 |
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