Menno Haven Rehabilitation Center

Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.Findings include: The facility's current policy regarding food temperatures, dated January 8, 2025, indicated that a tray line point of service standard for cold food must be held at a temperature of 31-41 degrees Fahrenheit (F) and hot food between 155-170 degrees F. A delivery standard for cold food must be served at a temperature between 33-50 degrees F and hot food at 135-155 degrees F. Interview with Resident 38 on August 11, 2025, at 11:30 a.m. included that the resident stated, the food is always cold when I get it. Interview with Resident 35 on August 11, 2025, at 12:10 p.m. included that the resident stated, the food just doesn't seem to stay hot. Interview with Resident 37 on August 11, 2025, at 12:30 p.m. included that the resident stated, the food would taste much better if it wasn't always cold. The menu for Wednesday (undated) revealed that the lunch meal included cold Italian couscous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a physician's order was obtained to provide specialized respiratory treatment for one of 25 residents reviewed (Resident 45).Findings include:The facility policy for non-invasive ventilation (CPAP- continuous positive airway pressure used to provide patent airway during periods of sleep apnea (breathing repeatedly stops and starts during sleep), dated January 8, 2025, revealed that the facility was to obtain an order for the use of the CPAP device and settings from the practitioner.An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 45, dated July 30, 2025, revealed that the resident was cognitively intact and used non-invasive ventilation. A care plan for the resident, dated July 23, 2025, revealed that the resident was to use CPAP per the physician's order. A nursing note, dated July 29, 2025, at 1:55 p.m. revealed that Resident 45 used CPAP at bedtime.There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies and clinical records, as well as interviews with residents, family members, and staff, it was determined that the facility failed to maintain professional practices that support infection prevention and control for one of 25 residents reviewed (Resident 35).Findings include: The facility's policy regarding hand hygiene, dated January 8, 2025, indicated that all team members will be trained and complete hand hygiene competencies at regular in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infections upon hire and no less than annually. Staff are to use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap at times that include before and after handling clean or soiled dressings, gauze pads, etc., after removing gloves, and before and after entering isolation precautions settings. The use of gloves does not replace hand washing/hand hygiene. The facility's Wound Care Observation Checklist for Infection Control, completed by Registered Nurse 2 on June 10, 2025, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs for two of 16 residents reviewed (Residents 17, 29). Findings include: The facility's policy regarding comprehensive care plans, dated June 12, 2024, indicated that the interdisciplinary team, in conjunction with the guest and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each guest. The comprehensive, person-centered care plan will include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the guest's highest practicable physical, mental, and psychological well-being. An admission MDS assessment for Resident 17, dated July 4, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated June 28, 2024, and resolved on July…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was thawed as per facility policy and that food stored in the kitchen was labeled, dated and secured. Findings include: The facility's policies regarding thawing frozen foods and food storage, dated June 12, 2024, revealed that food should never be thawed at room temperature and any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight. Observations in the kitchen on August 5, 2024, at 10:23 a.m. revealed that there was a total of 38 hot dogs thawing on the counter at room temperature. Observations in the walk-in cooler on August 5, 2024, at 10:27 revealed that there was approximately one cup of sage in a plastic bag that was undated and unsecured. Observations in the meat cooler on August 5, 2024, at 10:30 a.m. revealed that there was one piping bag (a kitchen tool in the shape of a cone used for decorating cakes, pies and pastries) full of whip cream that was undated and unsecured. Observations in dry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for three of 16 residents reviewed (Residents 11, 26, 29). Findings Include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated June 11, 2024, revealed that the resident was understood, could understand others, and had diagnoses that included a hip fracture. A care plan for the resident, dated July 5, 2024, revealed that the resident was on a Restorative Nursing Program for active range of motion, and the resident was to perform 15 ankle pumps (bend foot up and down at the ankle joint) and 15 ankle rolls (roll ankle to the right in a circular motion, and then to the left in a circular motion) two times per day. Review of nurse aide documentation for Resident 11, dated July and August 2024, revealed that staff documented the 15 ankle pumps and the 15 ankle rolls as Not Applicable (NA) during the day shift on July 24, 25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 16 residents reviewed (Resident 11). Findings include: The facility's policy regarding notification of changes, dated June 12, 2024, revealed that the physician was to be notified with any changes in a resident's condition. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated July 11, 2024, indicated that the resident was understood and could understand, was cognitively intact, required substantial assistance for care, was receiving a diuretic medication (a drug that causes increased urine output), and had diagnoses that included end-stage kidney disease. A care plan for Resident 11, dated July 5, 2024, revealed that the resident was on a diuretic for high blood pressure and required daily monitoring for effectiveness. Physician's orders for Resident 11, dated July 12, 2024, included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies, clinical records, and observations, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for one of 16 residents reviewed (Resident 50). Findings include: The facility's policy regarding baseline care plans (includes the minimum healthcare information necessary to properly care for a resident), dated June 12, 2024, indicated that the baseline care plan will be developed within 48 hours of a guest's admission, include the minimum healthcare information necessary to properly care for the guest including, but not limited to: initial goals based on admission orders, physician's orders, dietary orders, therapy orders, and social services. The admitting nurse or supervising nurse on duty shall gather information from the admission physical assessment, hospital transfer information, physician's orders, and discussion with the guest and the guest's representative. Interventions shall be initiated that address the guest's current needs. A nursing note for Resident 50,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician orders were followed for one of 16 residents reviewed (Resident 11). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated July 11, 2024, revealed that the resident was cognitively intact, depended on assistance from staff for daily care needs, and received a diuretic (a medication that increases urine output). A care plan, dated July 5, 2024, indicated that the resident was to receive diuretic per physician's orders. Physician's orders for Resident 11, dated July 29, 2024, included an order for the resident to receive 2 milligrams (mg) of Bumex (a diuretic) every 24 hours as needed for edema (swelling), if the resident has a 2-pound weight increase in one day. A review of Resident 11's Treatment Administration Record (TAR) for July and August 2024 revealed that the resident's weight on July 30 was 202 pounds, July 31 was 204 pounds, and August 1 was 216.8 pounds.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficient practices. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending September 7, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending August 7, 2024, identified repeated deficiencies related to quality of care and sanitary food preparation and storage. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending September 7, 2023, revealed that the facility developed a plan of correction that included completing audits and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed according to physician's orders for one of 19 residents reviewed (Resident 42). Findings include: The facility's policy regarding flushing intravenous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated July 12, 2023, indicated that central venous access catheters would be flushed after each infusion to clear infused medications. The facility's policy regarding medication administration, dated July 12, 2023, revealed that medications were to be administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards. Staff were to sign the Medication Administration Record (MAR) after the medication was administered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the review of the facility policies, as well as obervations and staff interviews, it was determined that the facility failed to ensure that food stored in the walk-in freezer was properly dated and labeled. Findings include: The facility's policy for food storage, dated July 12, 2023, indicated that all products were to be labeled and dated with the receiving date. All open items will have an open date and will be resealed to prevent contamination. Observations of the dietary walk-in freezer on September 5, 2023, at 11:14 a.m. revealed undated and/or unlabeled items that were not in their original delivery box, including a bin of chicken breasts (8 cases -multiple breasts in separate clear plastic bags), beef brisket in a clear sealed bag, one angel food cake in a tied plastic bag, multiple single serving macaroni and cheese in a plastic bin, two packages of sandwich buns in a plastic bag, and a partial loaf of gluten-free bread. Interview with the Executive Chef on September 5, 2023, at 11:30 a.m. confirmed that all items should have been dated and/or labeled. 28 Pa. Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete wound treatments as ordered by the physician for one of 19 residents reviewed (Resident 17). Findings include: An admission Minimum Data Set (MDS) assessment for Resident 17, dated August 17, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance for daily care tasks, and had a venous or arterial ulcer (ulcer caused by poor circulation). Physician's orders for Resident 17, dated August 15 and 29, 2023, included orders for the resident's right ankle to be cleansed with normal saline solution (sterile water), Opticell Ag (absorbent anti-bacterial dressing) applied, and covered with optifoam (foam dressing) three times a week. A care plan, dated August 14, 2023, indicated that wound care was to be provided as ordered. Review of Resident 17's Treatment Administration Records (TAR's) for August and September 2023 revealed that there was no documented evidence that the treatment to the resident's right ankle was completed three times a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.