NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER
For profit - Corporation
139 Beds
IMPERIAL HEALTHCARE GROUP
Data: November 2025
Trust Grade
20/100
#613 of 653 in PA
Photo by Newport Meadows Nursing and Rehabilitation Center (formerly Harrison House)
Photo by Newport Meadows Nursing and Rehabilitation Center (formerly Harrison House)
Photo by Newport Meadows Nursing and Rehabilitation Center (formerly Harrison House)
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Newport Meadows Health and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. Ranked #613 out of 653 facilities in Pennsylvania, it falls in the bottom half, and it is the lowest-ranked nursing home in Lancaster County. The facility is showing an improving trend, reducing issues from 11 in 2024 to 3 in 2025, which is a positive sign. However, staffing is a notable weakness, with a low rating of 1 out of 5 and a turnover rate of 53%, which is higher than average. There have been concerning incidents, including a serious medication error that required emergency treatment for a resident and a case where a resident suffered second-degree burns from improperly reheated coffee. Additionally, the facility incurred fines of $42,912, which is higher than 81% of Pennsylvania facilities and suggests ongoing compliance issues. While there are some improvements, families should weigh these serious weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- F
- In Pennsylvania
- #613/653
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $42,912 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
20/100
Bottom 7%
Review needed
11 → 3 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 3 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Pennsylvania average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 53%
Near Pennsylvania avg (46%)
Higher turnover may affect care consistency
Federal Fines: $42,912
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: IMPERIAL HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 37 deficiencies on record
3 actual harm
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:
Number of residents cited:
Based upon interview and clinical record review, it was determined that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:
Number of residents cited:
Based upon interview and clinical record review, it was determined that the facility failed to ensure appropriate notification was provided to a resident prior to a room change for one of twenty-five residents reviewed (Resident 16).Findings include:Review of Resident 16's diagnosis list revealed diagnoses including major depressive disorder (major loss of interest in pleasurable activities, characterized by changes in sleep patterns, appetite and/or daily routine), diabetes mellitus (failure of the body to produce insulin to enable sugar to pass through the bloodstream to cells for nourishment), and bladder cancer.Review of Resident 16's progress notes revealed that Resident 16 was sent to the hospital on August 11, 2025, related to abdominal pain.Further review of Resident 16's progress notes dated August 14, 2025, revealed resident arrived from hospital via stretcher with 2 attendants and taken to room [ROOM NUMBER] for admission, upon seeing [resident's] room had been changed, [resident] began hollering that [resident] was not going into that room. Resident continued to scream, reorienting to the situation as this is the room given [resident] in the admission process, [resident] continued to scream, reminded [resident] choice was to accept the room or return to the hospital [resident] stated, take me back; attendants exited building with [resident] on the stretcher to return to hospital.Interview with Resident 16 on September 8, 2025, at 1:00 p.m. revealed Resident 16 was not informed of his room change prior to the room change. This interview further revealed that Resident 16's room was changed while Resident 16 was a patient in the hospital.Interview with the Nursing Home Administrator on September 9, 2025, at 11:00 a.m. confirmed that Resident 16's room was changed while Resident 16 was in the hospital. The interview further confirmed that Resident 16 was not notified of the room change prior to the facility assigning the resident to a different room. 28 Pa. Code 201.18(b)(1)(2) ManagementPreviously cited 9/25/202428 Pa. Code 201.29(a)(b)(c) Resident RightsPreviously cited 9/25/2024
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, it was determined that the facility failed to ensure that privacy curtains were clean on one of five units (Dogwood unit).Findings include: The facility failed to ensure a clean ...
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Based on observation, it was determined that the facility failed to ensure that privacy curtains were clean on one of five units (Dogwood unit).Findings include: The facility failed to ensure a clean and homelike environment by not ensuring privacy curtains were clean when visibly soiled.Observations made on September 7, 2025, at 12:15 p.m., of 12 rooms on the Dogwood unit, revealed that nine of the residents' rooms had privacy curtains that were stained with brown and/or red substances, the rooms of Resident 7, Resident 22, Resident 47, Resident 50, Resident 53, Resident 54, Resident 56, Resident 59, Resident 68, Resident 78, Resident 88, Resident 94, Resident 108, Resident 112, Resident 121, and Resident 123.During an interview on September 9, 2025, at approximately 1:30 p.m., when the above was presented the Nursing Home Administrator (NHA) stated she would investigate the matter. During phone interview on September 15, 2025, at 10:20 am, the Director of Nursing (DON) stated housekeeping usually cleans the privacy curtains upon discharge of a resident or when notified the curtains are visibly soiled. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not ensure physician was notified of change in resident's condition/status. Based on review of clinical record,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not ensure physician was notified of change in resident's condition/status. Based on review of clinical record, facility policy, and staff interviews, it was determined that the facility failed to notify the physician of a change in condition/status for one of three residents reviewed (Resident R1). Findings include:Review of facility policy titled Change in a Resident's Condition or Status, revised 2021, revealed the facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician or physician on call when there has been a(an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse reaction to medication;d. significant change in the resident's physical/emotional/mental condition;e. need to alter the resident's medical treatment significantly;f. refusal of treatment or medications two (2) or more consecutive times);g. need to transfer the resident to a hospital/treatment center;h. discharge without proper medical authority; and/[NAME]. specific instruction to notify the physician of changes in the resident's condition.Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included severe protein calorie malnutrition (inadequate intake of essential nutrients, particularly protein and calories), epilepsy (brain condition that causes reoccurring seizures), and dysarthria (slurred speech). Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated May 13, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderately impaired cognition.Interview on July 18, 2025 at 12:05 p.m. with Employee E2, Licensed Practical Nurse, revealed he/she identified Resident R1 had increased slurred speech on the evening of July 17, 2025. Employee E2 confirmed he/she did not notify the physician or document his/her observation due to relating the slurred speech to Resident R1's previous respiratory illness he/she was recovering from since May 2025. Review of Resident R1's clinical record from the months of May 2025 through June 2025 revealed no progress note on slurred speech or worsening slurred speech related to respiratory illness. Interview on July 18, 2025 at 11:55 a.m. with Employee E1, Nurse Practitioner, confirmed when resident has change in condition/status for example slurred speech, staff is expected to document and notify physician. Review of Resident R1's nursing progress note, dated June 16, 2025 at 6:18 p.m., stated resident relative here and concerned as she has seen a dramatic negative change in him since Thursday. Noted by this nursing supervisor a dramatic change in vocal ability. His voice sounds as if his tongue is too big. Was able to follow conversation and was able to change an answer to a question from narrative to yes/no answer when asked about going to hospital for further evaluation. Relative getting guidance from wife. She has confirmed desire for him to be seen. Call out to on-call for confirmation. Review of Resident R1's nursing progress note, dated June 16, 2025 at 6:25 p.m., revealed Resident R1 was transferred to hospital for evaluation.Review of Resident R1's hospital record, dated June 17, 2025, revealed Resident R1 presented with worsening dysarthria, left sided chest pain and left shoulder pain. Patient was found to have elevated Dilantin level of 29.5. Exam notable for confusion, bilateral lower extremity weakness, and severe dysarthria. Further review of Resident R1's hospital record, dated June 18, 2025, stated the patient was found to be less responsive than normal yesterday with worsening slurred speech. Personally called [NAME] Meadows and spoke with Nursing Supervisor who stated she was informed that the patient had a steady decline in his speech over the weekend and when a visitor came to see the patient yesterday (Monday) the visitor thought the speech changes were more pronounced. Resident R1's hospital records revealed Resident R1 was diagnosed with Dilantin toxicity (prescription drug used to treat seizures, but it can cause severe toxicity if the dose is too high or if it interacts with other drugs.The facility failed to notify the physician in a timely manner related to a change in Resident R1's condition/status. Resident R1's family requested resident to be assessed, which resulted in resident being transferred to hospital and diagnosed with Dilantin toxicity. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1) Nursing services.
Nov 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure that residents were free from significant medication error for one of three residents, resulting in Resident R1 needing emergency medical treatment (Resident R1). This situation was identified as past non compliance.
Findings include:
Review of facility policy titled Administering Medications revealed number nine indicating the following: The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b.
checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel.
Further review of the facility policy revealed number ten which indicated: The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
Review of Resident R1's clinical record revealed diagnoses including but not limited to the following: Dementia (loss of thinking, remembering, and thinking skills) Chronic Kidney Disease Stage 3 (gradual loss of kidney function); Cerebrovascular Disease (condition that affects blood flow to the brain); Psychotic Disorder with Delusions; and Depression (persistent feeling of loss and lack of interest in activities of daily living).
Review of Resident R1's clinical record revealed a progress note dated October 13, 2024 (10:49 a.m.) Resident was mistakenly given (his/her) roommates medication which included carvedilol,lisinopril,clonidine and Keppra. [Resident's] BP/HR are low 74/40 and 42 [on call physician] returned the undersigned's call to the answering service and gave the directive for the resident to be sent to the hospital. [family member] contacted/apprised.
Further review of Resident R1's clinical record revealed a progress note dated October 13, 2024 (12:18 p.m.) indicating the undersigned mistakenly administered this residents' roommate's medications @ 0800, Resident was in the hallway sitting on a chair. After realizing this error @0900, the residents bp/HR (blood pressure/heart rate) was rechecked and was 72/40 HR42. Supervisor notified immediately. attempts to reach on-call @0910 Medications that were given are: Sinemet 25-100mg (medication used to treat Parkinson's disease), hydralazine HCI 100mg (medication used to treat high blood pressure), Carvedilol 25mg (medication used to treat high blood pressure), clonidine HCI 0. 1mg (used to treat high blood pressure), Keppra 750 mg (medication used to treat seizures), and Lisinopril 40mg (used to treat high blood pressure). resident is alert and oriented. On-call [physician] returned phone call to supervisor @ 10:28, and EMS (emergency medical service) was called. resident BP was continued to be monitored until MD instructions were received and EMS arrival, BP/HR fluctuated from 72/40 HR 46 to 74/38 HR 42 @ 10am, resident responded appropriately for situation. last set of BP/HR @1045 before EMT arrival was 74/38 HR46. POA (power of attorney) was notified.
Review of Resident R1's hospital progress notes dated October 14, 2024 through October 17, 2024, revealed under section titled Assessment and Plan Acute Conditions indicated number of accidental medication administration, number two Bradycardia (slow heart rate) improving, and number three Hypotension resolved.
Further review of Resident R1's hospital documentation revealed a progress note dated Ocober 16, 2024 by hospital physician noting history of HTN (Hypertension), who presented on 10/13/2024 after accidental medication administration at (his/her) skilled nursing facility - pt (patient) received ACEi (Angiotensin-converting enzyme (ACE) inhibitors are medicines that help relax the veins and arteries to lower blood pressure), hydralazine, clonidine, keprpa, sinemet, lisinopril that was meant for another patient. (He/she) arrived bradydcardic and hypertensive (high blood pressure of 180/120). (He/she) received glucagon for beta blocker reversal. admitted to ICU (Intensive Care Unit) for monitoring. Did require inotropic and vasopressor support. Weaned off of these interventions.
Review of facility documentation titled Verification of Investigation revealed under section titled detailed description of event indicated, On 10/13/24 at approximately 0744 (7:44 a.m.), (Licensed Practical Nurse) asked [Resident R1] if (his/her) name was Harry and the (Resident R1) replied yes. LPN then administered (Resident R2) medication to (Resident R1). At approximately 0900 [Resident R1] stated that (he/she) did not feel well, and the LPN took the blood pressure of the (resident), and it was noted to be at approximately 72/40. The LPN went to the (resident's) room and noted that [Resident R2] was in (his/her) bed, and (Licensed nurse Employee E2) accidently gave the incorrect medications to the wrong (resident).
Further review of facility documentation including section titled Assessment of resident/describe injury revealed the following: Assessment completed by RN (Registered Nurse) in house, VS (vital signs) taken and noted to have a change in condition. The (resident) laid flat and feet elevated, the fluids pushed. (Resident's) blood pressure remained low, (resident) remained conscious the entire time until the EMT (Emergency Medical Team) arrives and transported to the ER (emergency room).
Additional review of facility documention titled Verification of Investigation revealed under section titled Summary and Outcome of Investigative findings the following: Employee (Licensed Employee E2) did not follow facility policy and will receive a final written warning. Employee will have 3 consecutive observations to ensure understanding of identifying residents prior to administering medications.
Further review of facility documents including Employee E2 (LPN [NAME])'s statement which revealed [Resident R1] was sitting in the hallway and the first thing I did was go around and take my parameters for blood pressure medications and when I asked [Resident R1]if his name was Harry (he/she) stated yes. So I took (his/her) BP (blood pressure) and it was 136/78 or so. Then I administered Resident R2's medication to Resident R1. Then about 45 minutes later [Resident R1] was still sitting in the hallway and then (he/she) said I don't feel very well so I rechecked (his/her) blood pressure because I knew that I gave (him/her) all those blood pressure medications, and (his/her) blood pressure was really low 72/40 or something and then I walked back to (his/her) room and I was like oh no (he/she) is in A bed, not B bed so I realized (employee E2) had the wrong patient. Then (Employee E2) notified the supervisor right away, I got (him/her) back in bed laying flat and (Employee E2) kept rechecking (his/her) blood pressure every 10-15 minutes, it was fluctuating up and down at the time. RN supervisor called the on call and came over to assessed the (resident) .
The facility initiated a full sweep of all the residents to determine if any others received incorrect medications. The review of all residents did not reveal any other residents effected by the deficient practice. The facility began to provide education to all licensed staff regarding administration of medications including reeducation on proper medication administration policy and protocols. Review of education documentation revealed that education was completed on October 21, 2024.
Interviews conducted with three licensed staff (Employee E3, E4, E5) on November 10, 2024 revealed education was provided regarding medication administration and ensuring proper identification of resident prior to administering medications.
Interview conducted on November 10, 2024 at approximately 2:00 p.m. with the Director of Nursing confirmed that Resident R1 was given another resident's medications which resulted in the need for emergency medical intervention and hospitalization.
The facility failed to ensure that Resident R1 was free of significant medication error when facility staff administered roommate's medications (Resident R2) to Resident R1 causing a physical decline and needing emergency intensive evaluation and treatment.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(1)(e)(1) Management
28 Pa Code 201.18(b)(3)(e)(1) Management
28 Pa Code 211.12(c) Nursing services
28 Pa Code 211.12(d)(3) Nursing services
Sept 2024
7 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and procedure and clinical record and staff interview, it was determined the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and procedure and clinical record and staff interview, it was determined the facility failed to safely reheat a beverage for one of 32 residents reviewed causing actual harm to Resident 32 who developed a 2nd degree burn.
Findings Include:
Review of facility policy and procedure titled Microwave Use, undated, revealed staff should remove beverage from microwave, uncover, stir and insert thermometer probe into center of beverage item ensuring contact with beverage only. Check digital display for a maximum temperature of <165. Let sit for three minutes before serving.
Review of Resident 32's Progress Notes revealed a nursing entry dated July 10, 2024 at 8:16 a.m. indicating While administering medication [resident] states that [resident] burned [himself/herself] while drinking [his/her] coffee. [Resident] states, I asked him to heat up my coffee and I spilled it on myself. [Resident] reports [he/she] burned both [his/her] butt cheeks.
Further review of Resident 32's progress notes revealed a skin and wound note dated July 10, 2024 at 10:08 a.m. indicating staff reports resident sustained burns to bilateral (both) buttocks due to coffee on July 9. An assessment of the wound included in the progress note read as follows: wound 4, left buttock, 2nd degree burn, 16 cm (centimeters), x 16 cm x 0.1 cm. 60% erythema (redness), 20% intact fluid filled blister, 20% epithelial (pink or pearly white tissue and wrinkles when touched). Wound 5 right buttock, 2nd degree burn, 8 cm x 6.7 cm, 0.1 cm, 100% epithelial.
Review of Facility Action Plan, signed by the Nursing Home Administrator on September 4, 2024 revealed Resident 32 is a [AGE] year-old [male/female] with a BIMS (brief interview for mental status) of 15 (indicating no cognitive deficit). On July 9, 2024 [Resident] kept [his/her] coffee from dinner and asked for it to be heated up prior to bed (approximately 10:45 p.m.). (Nursing Employee E4) honored [his/her] request to heat the coffee and placed it in the microwave for approximately 30 seconds, three time (testing between each time).
Interview with the Director of Nursing on September 24, 2024 at 11:30 a.m. revealed (Nursing Employee E4) was asked to heat up coffee left over from dinner by Resident 32. He heated it up and when he returned Resident 32 said it wasn't hot enough, so he heated up and again Resident 32 said it was not hot enough. When he heated it up a third time, he left it on the bedside table for Resident 32 because it was the end of the shift.
On September 24, 2024 at 11:30 a.m. the facility was asked to provide any evidence the beverage was temperature tested each time it was heated up by the nursing Employee E4. The Director of Nursing stated, we do not have logs for when (Nursing Employee E4) heated up the coffee for Resident 32 and a statement was taken from (Nursing Employee E4) but was unable to be found.
The facility failed to ensure beverages that were heated in a microwave were safe temperature prior to serving to residents resulting in actual harm to Resident 32.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 201.29(c) Resident rights
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, and interview with staff, it was determined that the facility failed to dev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, and interview with staff, it was determined that the facility failed to develop a plan of care with interventions for two of 31 residents reviewed (Residents 26 and 93).
Findings include:
Observation on September 22, 2024, at 11:00 a.m. revealed Resident 26 was receiving oxygen at 2 liters per minute through a nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help).
Review of Resident 26's physician's orders included an order for oxygen at 2 Liter/minute via nasal cannula PRN (as needed).
Review of the Resident 26's current active care plan failed to reveal a care plan or interventions for oxygen therapy.
Interview with the Director of Nursing on September 25, 2024, at 9:50 a.m. confirmed that Resident 26 did not have a care plan for oxygen therapy.
Observation of Resident 93 on September 22, 2024, at 10:05 a.m. revealed the resident had a left wrist contracture (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen).
Review of Resident 93's clinical record including progress notes revealed a nurse's note dated August 13, 2024, which indicated, [Nurse] was made aware by bedside nurse that resident's left wrist is contracted and swollen. This bedside nurse does not know patient and asked an aide if this was resident's usual presentation. One aide stated no that is new, another aide stated that it has been like that for about 3 weeks. [Nurse] assessed and left wrist is a little swollen. [Resident 93] did not let [nurse] touch the wrist.
Further review of Resident 93's progress notes revealed a nurse's note on August 16, 2024, which stated: Hospice nurse stated to roll up a washcloth and put in his hand to slow the progression of the contracture.
Review of Resident 93's current active care plan failed to reveal a care plan addressing the resident's contracture and limited range of motion.
Review of Resident 93's [NAME] (tool used to instruct nurse aides on providing care to residents) revealed an intervention to apply a rolled up washcloth in left hand daily to slow progression of the contracture.
Observations of Resident 93 on September 22, 2024, at 10:05 a.m. and on September 25, 2024, at 11:00 a.m. revealed the resident did not have a rolled up washcloth in the left hand.
Interview with the Director of Nursing on September 25, 2024, at 11:30 a.m. confirmed there was no active care plan addressing Resident 93's contracture and that staff did not implement the intervention to use a rolled up washcloth in the resident's left hand.
483.21(b) Comprehensive care plans
Previously cited 10/20/23
28 Pa. Code 211.5(f) Clinical records
Previously cited 6/13/24, 10/20/23
28 Pa. Code 211.11(a) Resident care plan
28 Pa. Code 211.11(d) Resident care plan
Previously cited 10/20/23
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/20/23
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record review, it was determined the facility failed to follow physician orders in regard to fluid restriction for one of 25 residents reviewed (Resident 11).
Findings include:
Revie...
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Based on clinical record review, it was determined the facility failed to follow physician orders in regard to fluid restriction for one of 25 residents reviewed (Resident 11).
Findings include:
Review of Resident 11's physician orders revealed an order dated August 13, 2024, stating 1500 ml (milliliter) fluid restriction, 900 ml from nursing, 600 ml from dietary.
Review of Resident 11's clinical record failed to reveal evidence of fluid consumption amounts administered by nursing.
Review of Resident 11's dietary fluid consumption from August 13, 2024, through September 24, 2024, revealed on multiple dates Resident 11 consumed greater than the 600 ml fluid restriction as ordered by Resident 11's physician as follows:
August 13, 2024 - 1080 ml; August 16, 2024 - 720 ml; August 17, 2024 - 960 ml; August 18, 2024 - 1080 ml; August 19, 2024 - 880 ml; August 20, 2024 - 1340 ml; August 21, 2024 - 720 ml; August 22, 2024 - 920 ml; August 23, 2024 - 970 ml; August 25, 2024 - 3240 ml; August 26, 2024 - 840 ml; August 28, 2024 - 620 ml; August 29, 2024 - 730 ml; September 1, 2024 - 1080 ml; September 2, 2024 - 780 ml; September 3, 2024 - 1020 ml; September 4, 2024 - 1140 ml; September 7, 2024 - 1020 ml; September 9, 2024 - 660 ml; September 11, 2024 - 800 ml; September 12, 2024 - 1040 ml; September 13, 2024 - 710 ml; September 15, 2024 - 980 ml; September 16, 2024 - 960 ml; September 17, 2024 - 1740 ml; September 18, 2024 - 860 ml; September 19, 2024 - 1040 ml; September 20, 2024 - 720 ml; September 21, 2024 - 960 ml; September 22, 2024 - 1080 ml; September 24, 2024 - 960 ml.
Interview with the Director of Nursing on September 25, 2024, at 10:00 a.m. confirmed there was no nursing documentation to indicate Resident 11's fluid consumption from nursing and further confirmed Resident 11 did not adhere to the 600-milliliter dietary fluid restriction as ordered by Resident 11's physician.
28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services
Previously cited 10/20/2023, 6/13/2024
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on review of Consultant Pharmacy Reviews, it was determined the physician failed to ensure a rationale was provided in declining a Consultant Pharmacist recommendation for one of five residents ...
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Based on review of Consultant Pharmacy Reviews, it was determined the physician failed to ensure a rationale was provided in declining a Consultant Pharmacist recommendation for one of five residents reviewed (Resident 102).
Findings include:
Review of Resident 102's Consultant Pharmacy Medication Review dated March 27, 2024, regarding a Gradual Dose Reduction (GDR) revealed the physician disagreed with the request from the Consultant Pharmacist.
Further review of Resident 102's medication review failed to reveal a clinical rationale for declining the recommendation.
Interview with the Director of Nursing on September 25, 2024, at 10:15 a.m. confirmed no clinical rationale was provided by Resident 102's physician for declining the consultant pharmacist's recommendation.
28 Pa. Code 211.9(a) Pharmacy Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
Based on clinical record review, it was determined the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of 25 residents reviewed (Resident 2).
Finding...
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Based on clinical record review, it was determined the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of 25 residents reviewed (Resident 2).
Findings include:
Review of Resident 2's clinical record revealed a podiatry consult dated April 15, 2024, which stated that the resident was seen at request of floor nurse - [resident] had a fall a week or 2 ago & is complaining of pain in [left] foot.
Further review of same podiatry consult dated April 15, 2024 under the subsection titled Recommendations/New Orders the podiatrist wrote for the resident to have an x-ray of the left foot.
Review of Resident 2's progress notes revealed a nurse's note dated April 15, 2024, which stated: Resident seen by the Podiatrist today for [complaints of] left outer foot pain near [his/her] pinky toe. [No new orders] received.
Review of Resident 2's x-ray results revealed the x-ray was not obtained until April 23, 2024, which showed a fracture of the distal fifth metatarsal bone.
The delay in obtaining Resident 2's x-ray was confirmed with the Director of Nursing on September 25, 2024, at approximately 11:30 a.m.
Pa. Code: 211.12(b) Nursing services
Pa. Code: 211.12(d)(1)(3) (5) Nursing services
Pa. Code: 211.10(d) Resident care policies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on clinical record review and staff interview, it was determined that the facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for three of fi...
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Based on clinical record review and staff interview, it was determined that the facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for three of five residents reviewed for unnecessary medications (Residents 2, 84, and 93).
Findings include:
Review of Resident 2's physician's orders revealed an order dated March 31, 2023, for Abilify (antipsychotic medication) 5 milligrams (mg) once daily.
Review of Resident 2's clinical record failed to reveal evidence of side effect monitoring for the antipsychotic medication.
Review of Resident 84's physician's orders revealed an order dated September 14, 2024, for Abilify 10 mg once daily.
Review of Resident 84's clinical record failed to reveal evidence of side effect monitoring for the antipsychotic medication.
Interview with licensed nurse Employee E3 on September 25, 2024, at approximately 10:50 a.m. revealed side effect monitoring for residents on antipsychotics should be found on the residents' Medication Administration Record (MAR).
Review of Resident 2 and Resident 84's September 2024 MAR's failed to reveal evidence of side effect monitoring for the antipsychotic medications.
Review of Resident 93's physician's orders revealed an order dated July 1, 2024, for Risperidone (antipsychotic medication) 0.5 mg twice daily. Further review of Resident 93's orders revealed an order dated November 3, 2023, to monitor for side effects for antipsychotics every shift. Each side effect was numbered 1-14. Document N if monitoring was conducted and no side effects were observed; document Y if monitoring was conducted and side effects were observed.
Review of Resident 93's September 2024 Treatment Administration Record revealed staff were not documenting N or Y and the side effect monitoring was signed off via a checkmark and staff initials.
The above findings were confirmed with the Director of Nursing on September 25, 2024, at approximately 11:30 a.m.
28 Pa Code 211.5 (f) Clinical records
28 Pa code 211.10 (c) Resident care policies
28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate adherence to Infection Prevention measures in regard to COVID-19 for one of f...
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Based on review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate adherence to Infection Prevention measures in regard to COVID-19 for one of five units observed (1st Floor Chestnut Unit).
Findings include:
Review of facility policy and procedure titled Coronavirus Disease (COVID-19) - Resident Exposure, Quarantine and Isolation revealed staff will use full PPE (N95 or approved equivalent respirator, gown, gloves and eye protection) before entering the room and to provide care for the resident(s) in isolation; PPE will be discarded prior to exiting the room, or between care of residents residing in same room, with the exception of reusable universal eyewear to be cleaned at least daily and after patient encounter; N95 respirator will be removed and universal source control (i.e. facemask) will be worn upon exit if indicated.
Observation of the 1st Floor Chestnut Unit on September 22, 2024, at 9:30 a.m. revealed Licensed Employee E5 standing in the hallway outside a resident room. Licensed Employee E5 was wearing a cover gown, N95 and gloves and stated that he/she was testing residents on the unit due to a resident testing positive for COVID-19 the prior evening, September 21, 2024.
Further observation of the 1st Floor Chestnut Unit failed to reveal evidence of any staff persons wearing masks or providing any universal precautions.
Further observation of Licensed Employee E5 revealed the employee moving from room to room conducting COVID-19 tests without changing cover gown, N95 respirator, or gloves. Licensed Employee E5 was further observed to place a second pair of gloves over the first pair of gloves and not removing/changing the first pair of gloves between residents during testing. No handwashing or hand sanitization was observed to occur during the observation.
Observation of the entrance of the facility failed to reveal evidence that notification of COVID-19 presence in the building to family members or visitors.
Observation on September 23, 2024, at 8:30 a.m. of the entrance and reception area to the building failed to reveal notification of COVID-19 in the building and no monitoring of visitors was conducted.
Observation on September 24, 2024, and September 25, 2024, of the entrance and reception area failed to reveal notification of COVID-19 or any screening procedures, recommendations, or observations in place.
Interview with the Director of Nursing on September 25, 2024, at 10:30 a.m. confirmed Licensed Employee E5 should have changed all PPE prior to entering resident rooms; all staff should have been wearing face masks upon detection of a positive COVID-19 resident and additional screening completed at the entrance/reception area.
28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services
Previously cited 10/20/2023, 6/13/2024
Jun 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure the physician medication orders were accurately entered and followed for one of four residents reviewed (Resident CL1).
Findings include:
Review of CL1's clinical records revealed Resident CL1 was admitted to the facility on [DATE], with a diagnosis of Epilepsy (abnormal movements due to unusual electrical activity in the brain), and Irritable Bowel Syndrome (IBS- disorder that affects the stomach and intestines).
Review of Resident CL1's Hospital Discharge Summary, Medication List, revealed a list of the medications for the resident to take. The list includes an order for Prednisone (anti-inflammatory medication)10 mg. Take four tablets by mouth daily for five days, then three tablets daily for seven days, then two tablets daily for seven days, then one tablet daily for seven days. Start taking on May 19, 2024.
Review of Resident CL1's physician's order dated May 18, 2024, revealed Prednisone 10 mg four tablets by mouth every five days until May 23, 2024; three tabs by mouth daily until May 31, 2024, two tablets by mouth every seven days until June 6, 2024, and one tablet by mouth once daily until June 15, 2024.
Review of Resident CL1's May 2024, Medication Administration Record (MAR) revealed that the Prednisone 10 mg four tablets was transcribed to be given every five days instead of daily for five days which was the hospital's medication order sent to the facility. The MAR revealed that the Prednisone 10 mg four tablets was only administered on May 19, 2024, until the resident left the facility in the afternoon of May 21, 2024.
Interview with the licensed nurse, Employee E3 conducted on June 13, 2024, revealed upon residents' admission, hospital medication orders were reviewed by the nursing supervisor with the physician. If the physician does not agree with the hospital medication order, a note is written in the medication list from the hospital or on the resident's medical record. Employee E3 then reported that upon the physician's approval of the medication list from the hospital, the nursing supervisor enters the order into the physician's order and will automatically be transcribed in the resident's medication administration record. Employee E3 confirmed that licensed nurse Employee E4 entered the Prednisone order in the physician's order but was unable to provide an answer as to why it was entered as every five days instead of daily for five days.
Review of Resident CL1's clinical record failed to reveal documentation the physician wanted Prednisone 10 mg four tablets every five days instead of daily for five days which was the order from the hospital.
The facility failed to ensure that the hospital medication order was accurately entered into the physician's order.
Review of Resident CL1's physician order dated May 18, 2024, revealed an order for Mesalamine 800 mg given 1600 mg by mouth three times daily for IBS. The medication was scheduled to be administered at 12 midnight, 8:00 a.m., and 4:00 p.m.
Review of May 2024, MAR revealed that Mesalamine medication was not administered from the midnight of May 19, 2024, until the midnight of May 21, 2024.
Review of Resident CL1's clinical record revealed, Mesalamine medication was not administered due to the unavailability of the medication. Clinical records further revealed that the physician was notified of the missed medication from May 19, 2024, until midnight May 20, 2024. Clinical records review revealed physician was not notified that medication was still unavailable and therefore was missed on May 20, 2024, at 8:00 a.m., May 20, 2024, at 4:00 p.m., and May 21, 2024, at midnight.
The above information was conveyed to the Nursing Home Administrator on June 13, 2024.
The facility failed to ensure physician's order was accurately entered and followed.
28 Pa. Code 201.18(b)(1) Management
28 Pa. 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 211.5(f) Clinical records
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on a review of the facility's policy, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection con...
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Based on a review of the facility's policy, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for three of three residents reviewed (Residents R1, R2, and R3).
Findings include:
Review of the facility's policy titled Enhanced Barrier Precautions dated April 2024, revealed that EBP is indicated for residents with wounds and/or indwelling medical devices, regardless of MDRO (Multiple Drug Resistant Organism) infection or colonization status. Appropriate notification/signage is placed at the room entrance indicating the type of precaution and instruction for PPE (Personal Protective Equipment) use. PPE will be available to staff for donning before entering the resident's room.
Observation conducted on June 13, 2024, at 11:00 a.m., revealed Resident R1 in bed with a dressing on the left foot.
Review of Resident R1's clinical record revealed Resident R1 has a left heel ulcer.
Review of Resident R2's clinical record revealed Resident R2 has a sacral pressure ulcer.
Review of Resident R2's clinical records revealed Resident R3 has a left lateral foot wound.
Observation of Resident R1, R2, and R3'2 room entrances revealed no signage for EBP and no PPEs.
Interview conducted with licensed nurse, Employee E5 on June 13, 2024, confirmed Resident R1, R2, and R3 all have wounds. Employee E5 reported the staff had to request housekeeping to send PPEs to the unit if needed.
The above information was discussed with the Nursing Home Administrator on June 13, 2024.
The facility failed to ensure the EBP process was implemented for Resident R1, R2, and R3.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing service
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0635
(Tag F0635)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, and staff interview, it was determined that the facility failed to ensure that physician...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, and staff interview, it was determined that the facility failed to ensure that physician's orders for immediate care were obtained at the time of admission for one of three residents reviewed (Resident R2).
Findings include:
Review of R2's hospital discharge documentation dated February 29, 2024, revealed follow up appointments to include Nephrology, resident should continue dialysis on Tuesday, Thursday, and Saturday.
Review of R2's clinical records revealed an admission MDS dated [DATE], documenting resident receives dialysis treatments.
Further review of R2's clinical records revealed a care plan date March 1, 2024, documenting R2 has renal insufficiency and on dialysis three times a week related to end stage disease.
Review of R2's clinical records revealed physician's admission orders that failed to include orders for dialysis.
Interview with the NHA and Assistant NHA on March 11, 2024, at 3:10 p.m. confirmed that the physician's admission orders did not include orders for dialysis three days per week.
28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code: 201.18(b)(1) Management
28 Pa. Code: 211.5(f) Clinical records
Oct 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on clinical record review, facility documentation review, and staff interview it was determined the facility failed to develop and implement care plan goals/interventions for one of 24 residents...
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Based on clinical record review, facility documentation review, and staff interview it was determined the facility failed to develop and implement care plan goals/interventions for one of 24 residents reviewed. (Resident 62)
Findings Include:
Review of Resident 62's Progress Notes revealed a nursing entry on June 11, 2023 at 6:38 a.m. stating Witnessed fall CNA (Certified Nursing Assistant) was ambulating (walking) with resident in hall holding her right hand. Resident lost her balance and fell to her right knee then onto her buttocks.
Review of Resident 62's Incident Report, dated June 11, 2023 for the fall revealed an intervention of a UA (urinalysis) and C+S (culture and sensitivity) (lab studies to determine if there is an infection of the urinary tract and which bacteria it is and what antibiotics it is sensitive to).
Review of Resident 62's care plan for at risk for falls revealed an intervention added on June 11, 2023 for lab work.
Review of Resident 26's clinical record revealed no orders for the UA C+S to be completed or results of a UA C+S on June 11, 2023.
The facility failed to complete an interventions care planned for Resident 62 to help prevent falls after the fall of June 11, 2023.
Review of Resident 62's Progress Notes revealed a Physician Progress Notes dated August 23, 2023 at 4:20 p.m. stating the resident was e-admitted from the hospital after having a seizure.
Review of Resident 62's diagnosis list includes a diagnosis of unspecified convulsions with a date of August 15, 2023.
Review of Resident 62's orders revealed an order for Keppra (anti-seizure) 500 milligrams twice a day dated August 24, 2023.
Review of Resident 62's care plan failed to reveal a care plan for seizures developed after the resident returned from the hospital after having a seizure and with a new diagnosis of unspecified convulsions and being newly ordered anti-seizure medications.
Interview with Nursing Employee E3 on October 20, 2023 confirmed the care plan for Resident 62 did not address all of the current care needs and the intervention developed after the fall of June 11, 2023 was not completed.
28 PA Code 211.11(d) Resident care plan
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, clinical record review, and resident and staff interview it was determined the facility failed to follow physician orders for two of 24 residents reviewed and failed to notify p...
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Based on observations, clinical record review, and resident and staff interview it was determined the facility failed to follow physician orders for two of 24 residents reviewed and failed to notify physician of a change in condition for one of 24 residents reviewed. (Residents 74, 116, and 123)
Findings Include:
Review of Resident 74's diagnosis list revealed diagnoses including enlarged prostate, sepsis (blood stream infection) and Fournier's Gangrene (potentially fatal infection of the genital and perineum).
Review of Resident 74's progress notes dated August 23, 2023, revealed Resident noted with very foul-smelling urine output in foley [catheter] with hematuria [blood in urine]. Supervisor made aware. T. [temperature] 97.9 MD [physician] will be notified for further instruction.
Review of Resident 74's progress notes dated August 25, 2023, revealed Resident noted with dark red hematuria in foley. Supervisor made aware.
Review of Resident 74's progress notes dated September 18, 2023, revealed [podiatrist's - foot doctor] office called in regards to pt.[patient] Foley having hematuria in it. When going in to check pt. output Foley bag was slightly tinged with no urine. Bag changed to monitor baseline for pt.
Review of Resident 74's progress notes dated September 19, 2023, revealed Resident cont [continued] with hematuria 550 cc [cubic centimeter] with foul smelling urine. Resident afebrile [no fever]. Enc. Fluids; leg strap adjusted to prevent pulling. Cont to monitor.
Review of Resident 74's progress notes dated September 19, 2023, revealed CRNP [nurse practitioner] evaluated resident today following reports of hematuria. Continue to encourage fluids and urology is being consulted by CRNP, who will f/u [follow-up] with appt or new orders once speaks with uro [urology]. Hematuria is a known issue with this resident and at this time he presents without complaint. Will continue to monitor.
Review of Resident 74's nurse practitioner note dated September 19, 2023, revealed called [urology] for recommendations. Left message - will attempt to call again later today.
Review of Resident 74's progress notes dated September 19, 2023, revealed Upon further evaluation by NP resident noted with exceptionally large scrotum not present when catheter bag changed on 9/18 ordered transport to ER [emergency room] fir evaluation. Resident denies pain, presents otherwise at baseline, 400 ml of tea colored musty smelling urine drained from cath bag prior to transport at EMS [emergency services] request.
Follow up on September 20, 2023, with the hospital revealed Resident 74 was admitted to the Intensive Care Unit with a diagnosis of Fournier's Gangrene [type of necrotizing fasciitis (flesh-eating disease)].
Clinical record review revealed Resident 74 was readmitted to the facility from the hospital on October 4, 2023.
Interview with the Director of Nursing on October 20, 2023, at 1:00 p.m. confirmed Resident 74's physician was not notified of Resident 74's change in condition, i.e., foul smelling urine with hematuria as noted in August 2023 which continued until hospitalization in September 2023.
The facility failed to notify Resident 74's physician of a change in condition resulting in hospitalization of Resident 74.
Review of Resident 116's Physician orders revealed an order dated June 18, 2023 for Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) three times a day for 14 days (June 2, 2023).
Review of resident 116's progress notes revealed a nursing entry dated July 2, 2023 at 8:13 p.m. stating Nursing supervisor made aware by pt's (patient's) nurse that pt no longer had order for Ativan (lorazepam) in chart. Called CRNP on-call and rec'd (received) order for 1 day of Ativan until MD (physician) can come tomorrow. Then back on Dogwood, saw pt did have new order 6/29/2023 for Ativan, along with pre-filled med syringes in med cart on floor ready to be administered.
Review of the order placed in the electronic record on July 2, 2023 revealed a note stating, Order written 6/29/23 on label attached to bag of pre-filled gel syringes in med [medication] cart.
Review of Individual Patient Controlled Substance Administration Record revealed the facility received 60 syringes of Lorazepam for Resident 116 on June 29, 2023.
The facility was asked to provide the order that was referenced in the progress note dated July 2, 2023 at 8:13 p.m. and in the note on the order placed in the electronic record on July 2, 2023 and that was used to get a refill of the Lorazepam filled syringes that were delivered on June 26, 2023. The facility was unable provide the physician's order.
Review of Resident 116's Medication Administration Record for July 2023 revealed the resident did not receive Lorazepam as ordered from midnight of July 2 to 9 p.m. of July 2.
The facility failed to follow a physician order that was written on June 26, 2023 for Resident 116 to have lorazepam 0.5 mg three time a day on July 2, 2023.
Review of Resident 123's clinical records revealed Resident 123 had loose stools for eighteen out of thirty days in September 2023, and seven out of eighteen days in October 2023, according to Resident 123's bowel and bladder task sheet.
Review of Resident 123's physician orders revealed an order for Loperamide HCl Oral Capsule 2 MG dated July 26, 2023, with instructions to give 1 capsule by mouth every 8 hours as needed for loose stool.
Further review of Resident 123's physician orders revealed an order dated October 18. 2023, for a stool specimen for C-Diff (Clostridioides Difficile a bacterium that causes an infection of the large intestine (colon), one time only for diarrhea for 3 Days.
Review of Resident 123's Medical Administration Records revealed Resident 123 was given medication (Loperamide) for loose stool only four days in September 2023, September 7, 2023, September 14, 2023, September 17, 2023, and September 24, 2023. Additionally, Resident 123 was given medication (Loperamide) for loose stool on only two occasions on October 7, 2023, at 4:16 a.m., and 6:01 a.m.
Review of Resident 123's progress notes dated October 9, 2023, revealed a stool specimen was obtained and placed in the specimen refrigerator.
Further review of Resident 123's progress notes dated October 11, 2023, revealed a stool sample was collected by a previous shift and the specimen was placed in the specimen refrigerator on the unit.
Additional review of Resident 123's progress notes dated October 12, 2023, revealed a stool sample was collected and placed in the refrigerator. Progress notes dated October 12, 2023, indicated a lab slip is with the resident's C-Diff specimen, small, loose, yellow, foul-smelling stool this shift.
Further review of Resident 123's progress notes dated October 15, 2023; documents stool sample results are pending.
Review of Resident 123's records failed to reveal the stool specimen assessment results.
During interview with Director of Nursing on October 20, 2023, at 1:24 p.m., DON stated that only one stool specimen was taken from Resident 123. Per the DON, the sample was taken on October 9, 2023. The DON stated that the lab failed to pick up the specimen therefore the specimen had to be destroyed due to time expiration.
When inquiry was made regarding progress notes dated October 10, 2023, and October 11, 2023, that documented specimens were obtained and put in the refrigerator, progress notes from October 12, 2023 that documented a lab slip was in with Resident 123's stool specimen and progress notes from October 15, 2023, documenting that specimen was obtained and pending results, the DON stated that she was only aware of the October 9, 2023, specimen and that she would follow up with the laboratory for additional clarification.
Follow up interview with Director of Nursing on October 20, 2023, at 02:20 p.m. revealed that the laboratory never received a stool specimen for Resident 123.
The facility failed to ensure Resident 123's stool specimen was obtained and assessed by the laboratory.
28 Pa. Code 201.18(b)(1) Management
Previously cited 11/17/22, 9/14/22, 1/27/23
28 Pa. 211.12(d)(1)(3)(5) Nursing services
Previously cited 11/17/22, 9/14/22. 1/27/23
28 Pa. Code 211.5(f) Clinical records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based upon clinical record review and staff interview, it was determined that the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of five residents reviewed...
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Based upon clinical record review and staff interview, it was determined that the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of five residents reviewed (Resident 37).
Findings include:
Review of Resident 37's clinical record included diagnoses of but not limited to type 2 diabetes (condition resulting from insufficient production of insulin, resulting in high blood sugar), dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), and severe protein-calorie malnutrition.
Review of Braden Scal for Predicting Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) Risk Evaluation completed on September 22, 2023, revealed a score of 14 (moderate risk of developing a pressure ulcer).
Review of nursing progress note of September 22, 2023, revealed resident noted with open area to right buttock, no redness surrounding wound bed, no drainage noted, cleansed with NSS [normal saline] and DSD [dry sterile dressing] applied.
Additional note of September 22, 2023, revealed that resident had open area to right buttock, area is approximately a quarter size on right side of buttock. Additional note on same date revealed NP [nurse practitioner] gave order for medihoney [used for wound treatment] and dressing to site.
Further review of the clinical record revealed no further evaluations of the wound including the stage, description, infection, pain, or description of dressings and treatment from September 22, 2023, to October 20, 2023.
Interview with Employee E4 on October 20, 2023, at 12:55 p.m. confirmed that there was no documentation for the continued assessment of Resident 37's pressure ulcer.
28 Pa. Code: 211.5(f) Clinical records
Previously cited 12/9/22
28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 12/9/22
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed.
Findings in...
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Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed.
Findings include:
Review of staffing records and performance reviews revealed five staff members did not have annual performance reviews performed.
Interview with the Nursing Home Administrator on October 20, 2023 at 1:00 p.m. confirmed staff performance reviews were not completed.
28 Pa. Code 201.20(a)(c) Staff Development
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12 hour annual re-training for four of five records rev...
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Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12 hour annual re-training for four of five records reviewed.
Findings Include:
Review of five staffing records and inservice documentation revealed one nurse aide received the required 12 hour annual retraining.
Further review of the staffing records and inservice documentation revealed four of the five records reviewed failed to reveal evidence of retraining.
Interview with the Nursing Home Administrator on October 20, 2023 at 1:00 p.m. confirmed that the nurse aides did not received the required in-service retraining.
28 Pa. Code 201.20(a)(c) Staff Development
Sept 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interviews and observation, it was determined that the facility failed to effectively communicate updated meal times to residents, resident representatives, and staff on two of five units (Do...
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Based on interviews and observation, it was determined that the facility failed to effectively communicate updated meal times to residents, resident representatives, and staff on two of five units (Dogwood and Chestnut).
Findings include:
Tour of the facility on September 6, 2023, at approximately 10:00 a.m. failed to reveal posted meal times.
Interviews with residents R1, R2, and R3 on the Chestnut unit on September 6, 2023, from approximately 10:15 to 10:45 a.m. revealed all residents believed lunch was supposed to be served at 11:50 a.m., and all three residents reported meals were routinely late.
Interview with Employees E3, E4, E5, and E6 on the Dogwood unit on September 6, 2023, at 11:30 a.m. revealed the Dogwood unit was supposed to be served first, and meals were routinely late. Employees showed the surveyor a copy of the meal times, with the first lunch cart scheduled to be delivered to Dogwood was 11:30 a.m. Observation of the Dogwood dining room at this time revealed the residents were seated at tables waiting for lunch to be served.
Continued observation on the Dogwood unit revealed the first cart was not brought up until 12:30 p.m., one hour late according to the meal times the staff had access to.
Interview with Resident 4's representative on September 6, 2023, at 12:35 p.m. revealed the representative visits Resident 4 almost every day, and meals are late very often. The representative reported they could not go back to the Dogwood unit until the residents were finished eating, as the resident would get confused as to why the representative was not served a meal. The representative reported that the delays in meals being served were frustrating due to having to wait to visit with the resident until after meals were finished.
Interview with Resident 5 on the Chestnut unit on September 6, 2023, at 12:40 p.m. revealed the resident stated Lunch is late yet again. The resident appeared frustrated.
Continued observations on the Chestnut unit revealed the first lunch cart was delivered to the unit at 12:50 p.m., one hour late according to the meal times the staff had access to.
Interview with the Nursing Home Administrator on September 6, 2023, at approximately 12:55 p.m. revealed the facility had new meal times. The surveyor was handed an undated paper with meal times that indicated the first cart for lunch was to arrive on the Dogwood unit at 12:00 p.m., and the cart for lunch was to arrive on Chestnut at 12:30 p.m.
Follow up interview with the Nursing Home Administrator and District Manager on September 6, 2023, revealed the new meal times went into effect recently. The surveyor was not provided an exact date for when the new meal times went into effect.
The facility's failure to ensure residents, representatives, and staff were aware of updated meal times, and the residents on Dogwood being set up for and waiting an hour for lunch, was discussed at exit with the Nursing Home Administrator and Interim Director of Nursing on September 6, 2023, at approximately 3:30 p.m.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(1) Management
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected 1 resident
Based on staff interview and facility documentation review, it was determined that the facility administration failed to provide timely information for the documentation and calculation of the facilit...
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Based on staff interview and facility documentation review, it was determined that the facility administration failed to provide timely information for the documentation and calculation of the facility's nursing care hours, causing a delay in the survey process.
Findings include:
During an initial interview with the Director of Nursing (DON) on September 6, 2023, at approximately 9:00 a.m., three weeks of nurse staffing ratios and hours were requested (Week of July 23, 2023, August 6, 2023, and August 27, 2023). The staffing calculation and ratio spreadsheet was provided to the DON once internet services was provided to the surveyor at 9:40 a.m.
On September 6, 2023, at 3:11 p.m., the Nursing Home Administrator (NHA) emailed the surveyor the staffing ratios for the weeks of July 23, 2023, August 6, 2023, and August 20, 2023 (a week that was not requested by the surveyor).
During an exit interview with the NHA on September 6, 2023, at 3:30 p.m., the surveyor was provided with staffing calculations for the week of August 6, 2023, and three days of the week of August 23, 2023 (a week that was not requested by the surveyor). The surveyor enquired of the delay in receiving the information, and the NHA stated, someone in a sister facility was helping to put the information together. The surveyor asked how the facility was ensuring the facility was safely staffed if the staffing information was not readily available; the surveyor did not receive an answer. The surveyor informed the NHA that all the staffing ratios and calculations were required by early in the morning of September 7, 2023.
The surveyor contacted the facility on September 7, 2023, at 9:03 a.m The receptionist stated that the NHA was not in the facility and the DON could not be located. The receptionist indicated the NHA or DON would be informed and asked to call the surveyor back.
The surveyor emailed the NHA on September 7, 2023, at 9:10 a.m., informing the NHA that the staffing information still had not been received.
The surveyor received an email from the NHA on September 7, 2023, at 11:24 a.m. with the completed nurse staffing ratios and hours. The surveyor received a follow up email from the NHA at 11:28 a.m. alleging that the requested information was sent to the surveyor via email at 7:45 a.m. The surveyor did not receive an email at 7:45 a.m., and the first correspondence received from the NHA on September 7, 2023, was not until 11:24 a.m.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa code 201.18(a)(d)(e)(1) Management
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and interviews with the resident and staff it was revealed that the facility did not administe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and interviews with the resident and staff it was revealed that the facility did not administer medications according to physician orders for one of 3 residents reviewed (R1).
Findings include:
Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with closed Ulna Fracture (bone in the forearm), a right Acetabular Fracture (socket of the hip) and Diabetes Type II.
Interview conducted with Resident R1 at 11:30 a.m. on January 27, 2023, revealed that he/she had not received the morning medications. Review of Resident 1's MAR revealed, the medications ordered to be given at 8 a.m. were not given.
An interview with licensed Employee E3, Corporate Nurse, was conducted at 11:35 a.m. confirmed the medications that were not given inluding but not limited to Enoxaparin Sodium Solution Prefilled Syringe 40 MG (miligrams)/0.4ML Inject 0.4 ml subcutaneously one time a day for DVT (blood clots) Prophylactic for 26 days, and Metformin HCl Tablet 1000 mg (1 pill twice a day) for diabetes.
The facility failed to ensure Resident R1 medications were given according to physician orders.
28 Pa. Code 201.18(b)(1) Management
28 Pa. 211.12(d)(1)(3)(5) Nursing services
Dec 2022
14 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record reviews, and staff interview, it was determined that the facility failed to notify a m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record reviews, and staff interview, it was determined that the facility failed to notify a medical speciality practitioner (cardiologist) timely of a change in condition for one of 32 residents reviewed (Resident 56).
Findings include:
Review of facility policy, Change in a Resident's Condition or Status, revealed that the facility will promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.
Review of Resident 56's clinical record revealed, the resident was admitted to the facility on [DATE], with admitting diagnosis of Chronic Systolic (congestive) Heart Failure (excessive body fluid caused by a weakened heart muscle).
Further review of the clinical record revealed a physician's order dated September 7, 2022, for daily weights in the morning related to congestive heart failure and contact cardiologist with weight gain greater than 3 lbs (pounds).
Review of the daily weights revealed on December 6, 2022, a weight of 210 lbs was recorded. On December 7, 2022, a weight of 214 lbs. was recorded, a gain of 4 lbs. There was no further documentation in the clinical record that indicated the cardiologist was notified.
An interview with the Director of Nursing on December 9, 2022, at 1:00 p.m. confirmed the cardiologist was not notified.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 210.18(b)(3)(e)(1) Management
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected 1 resident
Based on review of facility policy, employee personnel files, and staff interview, it was determined the facility failed to obtain a criminal background check one of five employees reviewed (Employee ...
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Based on review of facility policy, employee personnel files, and staff interview, it was determined the facility failed to obtain a criminal background check one of five employees reviewed (Employee E12).
Findings include:
Review of the facilit policy titled, Abuse Prevention Program, revealed the facility will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
Review of Employee E6's personnel file revealed a hire date of September 27, 2022. There was no documented evidence, the facility had completed a pre-employment criminal background check.
Interview with the Nursing Home Administrator on December 9, 2022 at 12:35 p.m. confirmed there was no documented evidence regarding a criminal background check for Employee E6.
483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition
28 Pa. Code 201.14 (c) Responsibility of licensee
28 Pa. Code 201.18 (b)(1)(e)(1) Management
28 Pa. Code 201.29 (a) Resident rights
28 Pa. Code 211.10 (d) Resident care policies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of facility policy and procedures, review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to conduct a comprehensiv...
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Based on review of facility policy and procedures, review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to conduct a comprehensive investigation for an allegation of abuse and injury of unknown origin for three of 24 residents reviewed (Residents 37, 82, and 122).
Findings include:
Review of facility policy, Accidents and Incidents - Investigating and Reporting, revised July 2017, indicated that all accidents or incidents involving residents shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident, incident, and injuries of unknown origin.
Review of Resident 37's progress notes dated December 5, 2022 revealed a late entry from December 4, 2022 which revealed Resident reported that there is a male resident that has made unwanted advances at her. Reported to supervisor. Supervisor in to speak with resident. She informed this nurse that she does not want to change her room. Monitored this resident visually and no male residents seen near her or seeking her out at this time.
Interview with Resident 37 on December 5, 2022 at 10:00 a.m. failed to reveal any information regarding unwanted advances from a male resident.
Interview with the Nursing Home Administrator on December 9, 2022 at approximately 1:00 p.m. confirmed that a grievance form was entered into the grievance log, but no formal investigation into an allegation of abuse was conducted.
Review of Resident 82's annual MDS (Minimum Data Set - periodic assessment of resident needs) of May 17, 2022, revealed resident with both short term and long term memory issues and moderate impairment for decision making. Diagnoses included Alzheimer's dementia ( progressive disease that destroys memory and other important mental functions).
Review of Resident 82's progress note of August 8, 2022, revealed resident noted with the left knee swollen and complaining of pain. The physician was made aware and order an x-ray of the left knee.
Review of progress note of August 9, 2022, revealed x-ray results showed a left tibia (shin bone) fracture.
Interview with the Director of Nursing on December 8, 2022, at 8:56 a.m. revealed that an investigation into Resident 82's injury of unknown origin was not conducted.
Review of Resident 122's quarterly assessment of May 24, 2022, revealed a BIMS (Brief Interview for Mental Status - structured evaluation aimed at evaluating aspects of cognition) score of 12, indicating moderate cognitive impairment.
Review of progress note dated June 1, 2022, revealed resident with a new purplish bruise 6 cm (Centimeter) x 14 cm right flank portion of right hip region. Resident indicated I do not know how it happened.
Review of facility documentation revealed that there were no witnesses and no conclusion reached by the facility into how the resident obtained the bruise.
Interview with Employee E9, regional director, on December 9, 2022, at 11:22 a.m. revealed the facility practice is to minimally obtain statements for the previous 24 hours from staff in an attempt to determine the cause of the bruise. Employee E6 confirmed that there was no documented staff statements and a thorough investigation had not been completed to determine the cause of the injury.
483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition
483.12 - Investigate/Prevent/Correct Alleged Violation
Previously cited 10/17/22
28 Pa. Code 201.18(b)(1) Management
Previously cited 11/17/22, 10/17/22, 1/12/22, 10/26/21
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a)(c) Resident rights
28 Pa. Code 201.29(d) Resident rights
28 Pa. Code 211.5(f) Clinical records
Previously cited 10/26/21
28 Pa. Code 211.10(d) Resident Care Policies
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for three of 24 residents reviewed...
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Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for three of 24 residents reviewed (Residents 19, 72, and 75).
Findings include:
Review of Resident 19's progress note of June 25, 2022, revealed that the nurse was called to the resident's room and the resident was found on the bathroom floor. Resident complained of left arm pain and x-rays were ordered, which were negative.
Review of progress note of June 27, 2022, revealed the resident complained of pain in the arm due to swelling. Resident was sent to the hospital and returned with a diagnosis of closed fracture of the proximal end of the left humerus (bone of the upper arm).
Review of Resident 19's quarterly assessment of August 4, 2022, section J1800 indicated that the resident had a fall(s) since admission or the prior assessment. Review of section J1900 indicated that the resident had one fall with injury (except major).
Review of Resident 72's admission orders of September 27, 2022, included an order for hemodialysis every Tuesday, Thursday, and Saturday. Review of progress notes revealed resident was out for dialysis on September 29 and October 1, 2022.
Review of Resident 72's admission MDS of October 2, 2022, section O - Special Treatment and Programs indicated that resident did not receive dialysis while a resident.
Review of Resident 75's progress note of September 11, 2022 revealed resident observed walking with an aide to the dining room when the resident's leg give up and resident was lowered to the floor by the aid and supervisor. Resident complained of left knee pain and orders were obtianed for x-ray to the left knee to rule out dislocation or fracture. X-ray completed and negative for dislocation or fracture. Progress note of September 12, 2022, revealed resident has swollen left ankle. Physician ordered x-ray to the left ankle. Review of progress note of September 13, 2022, revealed x-ray results showed a transverse fracture through the near base of the medial malleolar region (ankle fracture).
Review of Resident 75's discharge assessment of October 3, 2022, section J1800 indicated that the resident had a fall(s) since admission or the prior assessment. Review of section J1900 indicated that the resident had one fall without injury and one fall with injury (except major).
Interview with licensed staff, E5, on December 9, 2022, confirmed that the assessments were coded inaccurately.
28 Pa. Code 211.5(f) Clinical records
Previously cited 10/26/21
28 Pa. Code 211.12(c) Nursing services
Previously 1/12/22, 10/26/21
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 1/12/22
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview it was determined that the facility failed to complete a baseline care plan for one of 32 residents reviewed (Resident 17).
Findings include:
Revie...
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Based on clinical record review and staff interview it was determined that the facility failed to complete a baseline care plan for one of 32 residents reviewed (Resident 17).
Findings include:
Review of Resident 17's clinical record revealed an admission date on May 3, 2022, with the diagnosis of dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). An elopement evaluation was completed on May 3, 2022 fininding that the resident would be at risk for elopement do to wandering behavior, not accepting the placement and verbal expression of the desire to go home.
Further review of the clinical record revealed a nursing note on May 5, 2022, stating the resident went out the door with staff watching and got her back into the building without incident.
Review of the clinical record revealed that elopement risk was not added to the care plan and interventions were not put inot place.
Interview with the Nursing home administrator on December 8, 2022, at 9:35 a.m. confirmed that they do not have an elopement care plan for the resident.
28 Pa. Code: 211.11(e) Resident care plan
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to implement a comprehensive care plan for prevention of falls for one of six sampl...
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Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to implement a comprehensive care plan for prevention of falls for one of six sampled residents reviewed (Resident 62).
Findings include:
Review of facility policy and procedure titled Falls and Fall Risk, Managing revised March 2018, revealed Resident conditions that may contribute to the risk of falls include: incontinence.
Further review of facility policy and procedure revealed The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.
Review of Resident 62's current care plan revealed Resident 62 was at risk for falls with an intervention of prompt toileting every two hours.
Review of Resident 62's clinical record dated October 8, 2022, revealed Resident 62 was found on floor of bathroom; left middle forehead bruise - trying to et up from the toilet and just slip and fell. Review of a witness statement dated October 8, 2022, revealed resident rang bell walked in the room resident on the floor, stated she grabbed the rail fell face down on the floor while trying to use the bathroom. Toilets self; incontinent.
Further review of Resident 62's clinical record dated October 16, 2022, revealed unit nurse and two aides were doing rounds nearby when they all heard the loud 'BANG' and the resident crying out. All three went to the room to see the resident on the floor near the toilet and almost right next to her roommate's bed. Resident admitted to hitting the back of head, suffered a lump, denied pain except only when the lump was touched. No other injuries noted. Per resident, she was 'rushing to go to the toilet.' Denied any dizziness prior to fall. Review of a witness statement dated October 16, 2022, revealed last seen around change of shift, 1st rounds, lying in bed.
Further review of Resident 62's clinical record dated October 22, 2022, revealed received call from med (medication) nurse, stated resident fell. Observe resident sitting up on the right side of bed.
Further review of Resident 62's clinical record dated October 22, 2022, revealed Resident 62 stated I tried to go to the bathroom.
Further review of Resident 62's clinical record dated November 15, 2022, revealed heard clattering noise and shouting, went to find where it came from and roommate activated call bell. Resident was lying on the floor with her rollator tipped over, awake and alert bleeding from the right forehead above brow. No other noted injury.
Further review of Resident 62's clinical record dated November 15, 2022, revealed Resident 62 stated she was going to the bathroom and fell.
Resident 62 was transported to an acute care facility and received sutures to the forehead laceration.
Interview with the Director of Nursing on December 9, 2022, at 11:00 a.m. revealed that no documentation existed as evidence that prompt every two hour toileting occurred for Resident 62 as stated on Resident 62's current plan of care.
The facility failed to implement Resident 62's comprehensive care plan for fall interventions put into place to prevent falls and injury to Resident 62.
28 Pa. Code 211.11(a)(b)(c) Reisdent care plan
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 10/26/2021, 1/12/2022, 9/14/2022, 11/17/2022
28 Pa. Code 211.12(c) Nursing Services
Previously cited 10/26/2021
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a comple...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was done for one of three residents reviewed (Resident 123).
Findings include:
Review of Resident 123's clinical record revealed that the resident was admitted to the facility on [DATE].
Review of progress notes revealed that the resident expired on [DATE].
Further review of the clinical record revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility.
Interview with the Nursing Home Administrator on [DATE], confirmed that the discharge summary was incomplete, as it was missing the physician's discharge summary.
28 Pa Code 211.5 (f) Clinical records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined the facility failed to follow physician orders for the administration of pa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined the facility failed to follow physician orders for the administration of pain medication and for weight gain for two of two residents reviewed (Resident 37 and Resident 56).
Findings include:
Review of Resident 37's physician orders revealed an order dated November 8, 2022, for Morphine Sulfate Solution 20 milligrams (mg)/milliliter (ml) administer 5 mg every 3 hours as needed for pain/distress moderate to severe pain.
(Pain is rated on scale of 1-10 with moderate to severe pain indicated by rate of 6-10).
Review of Resident 37's November 2022 Medication Administration Record (MAR) revealed, Resident 37 was administered Morphine Sulfate Solution as follows: November 15, 2022 for pain level of 0; November 18, 2022 at 3:00 a.m. for pain level of 3, 6:14 a.m. for pain level of 3; November 22, 2022 for pain level of 0; November 25, 2022 for pain level of 3; November 27, 2022 at 12:40 a.m. for pain level of 0, at 5:33 a.m. for pain level of 4 and 6:45 p.m. for pain level of 3.
Review of Resident 37's December 2022 MAR, revealed Resident 37 was administered Morphine Sulfate Solution on December 4, 2022, at 3:59 p.m. for a pain level of 0.
Interview with the Director of Nursing and Nursing Home Administrator on December 9, 2022, at 12:00 p.m. confirmed that Resident 37 failed to receive Morphine Sulfate Solution according to physician orders in November and December 2022.
Review of Resident 56's clinical record revealed, the resident was admitted to the facility on [DATE], with admitting diagnosis of chronic systolic (congestive) heart failure (excessive body fluid caused by a weakened heart muscle).
Further review of the clinical record revealed a physician's order dated September 7, 2022, for daily weights in the morning related to congestive heart failure and contact cardiologist with weight gain greater than 3 lbs (pounds).
Review of Resident 56's clinical record revealed a nursing note dated Novemeber 12, 2022, indicating Resident's weight was 213 lbs this am; 210 lbs 11/11; 211 lbs 11/10; 212 lbs 11/9;an order exists to contact the resident's cardiologist for a 3 lb wt gain.The resident's physician will be apprised to determine if cardiology should be contacted.
An interview with the Director of Nursing on December 9, 2022, at 1:00 p.m. revealed that the cardiologist was not notified as ordered.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 1/12/2022. 9/14/2022, 11/17/2022
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for three of nine residents reviewed for nutrition (R...
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Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for three of nine residents reviewed for nutrition (Residents 69, 100, and 107).
Findings include:
Review of Resident 69's vital signs revealed a weight of 167.6 pounds on May 12, 2022. Review of weight on June 13, 2022, revealed a weight of 157.4 pounds (10.2 pounds or 6.09% loss in one month).
Review of vital signs revealed a reweight of 153.4 pounds on June 21, 2022 (8 days later).
Review of progress notes revealed weight loss not addressed until June 29, 2022 (16 days after the initial weight loss).
Interview with Employee E4 on December 9, 2022, at 9:48 a.m. revealed that monthly weights should be completed by the 5th of the month. Employee E4 also revealed that reweights should be done for a 5% or greater weight loss within a few days of the initial weight. Employee E4 confirmed that the reweight was not obtained timely for Resident 69.
Review of Resident 100's weight summary revealed a weight of 115.6 pounds on May 7, 2022.
Further review of Resident 100's weight summary revealed a weight of 106.6 pounds on June 8, 2022 reflecting a 7.79% weight loss in one month.
Review of Resident 100's clinical record failed to reveal evidence of a reweight after the June 8, 2022 weight loss and progress notes revealed the weight loss was not addressed until June 30, 2022 (twenty-two days after the initial weight loss).
Review of Resident 107's weight summary revealed a weight of 200 pounds on June 8, 2022.
Further review of Resident 107's weight summary revealed a weight of 179.4 pounds on July 8, 2022 reflecting a 10.3% weight loss in one month.
Review of Resident 107's clinical record failed to reveal evidence of a reweight after the July 8, 2022 weight loss and progress notes revealed the weight loss was not addressed until July 28, 2022 (twenty days after the initial weight loss).
Interview with Employee E4 on December 9, 2022, at 9:48 a.m. revealed that monthly weights should be completed by the 5th of the month. Employee E4 also revealed that reweights should be done for a 5% or greater weight loss within a few days of the initial weight. Employee E4 confirmed that the reweight was not obtained timely for Resident 100 and Resident 107.
28 Pa. Code 211.5(f) Clinical Records
Previously cited 10/26/21
28 Pa. Code 211.10(c) Resident Care Policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 11/17/22, 9/14/22, 1/12/22, 10/26/21
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to notify the physician of the results of a laboratory test for one of one resi...
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Based upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to notify the physician of the results of a laboratory test for one of one resident reviewed (Resident 37).
Findings include:
Review of facility policy and procedure titled Anticoagulation - Clinical Protocol revised 2018 revealed The physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions with anticoagulants; for example, digoxin, dilantin, amiodarone and many antibiotics. The physician should adjust the anticoagulant dose or stop, taper or change medications that interact with the anticoagulant, and/or monitor the PT/INR (prothrombin time [PT] test measures how long it takes for a clot to form in a blood sample. INR [international normalized ratio] is a type of calculation based on PT test results. Prothrombin is a protein made by the liver. It is one of several substances known as clotting (coagulation) factors) very closely while the individual is receiving warfarin, to ensure that the PT/INR stabilizes within a therapeutic range.
Review of Resident 37's diagnosis list revealed diagnoses including Deep Vein Thrombosis (condition occurs when a blood clot forms in a deep vein).
Review of Resident 37's clinical progress notes dated August 24, 2022, revealed this nurse completed audit of coumadin book. This resident is on coumadin, last PT/INR on August 5, 2022, was unable to find lab from August 5, 2022, or any documentation that lab was reviewed with physician.
Review of Resident 37's August 2022 physician orders revealed Resident 37 was receiving Coumadin 2.5 milligrams (mg) once per day. Further review of Resident 37's physician orders revealed Resident 37 was to have a PT/INR laboratory test on August 5, 2022. The results of which were to be reviewed with the physician to determine the next Coumadin dose.
Review of Resident 37's clinical record revealed Resident 37's PT/INR laboratory test result was high and outside the reference range.
Further review of Resident 37's clinical record failed to reveal evidence Resident 37's physician was notified of the August 5, 2022, laboratory result until August 24, 2022, and Resident 37 continued to receive Coumadin 2.5 mg daily.
Interview with the Director of Nursing and Nursing Home Administrator on December 9, 2022, at 1:00 p.m. confirmed that Resident 37's physician was not notified of the August 5, 2022, laboratory result and further confirmed Resident 37 continued to received Coumadin 2.5 mg without the physician's knowledge.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 1/12/2022, 9/14/2022. 11/17/2022
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on review of facility policy, review of personnel records, and staff interviews, it was determined that the facility failed to ensure newly hired employees received the abuse training for three ...
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Based on review of facility policy, review of personnel records, and staff interviews, it was determined that the facility failed to ensure newly hired employees received the abuse training for three of five personnel records reviewed (Employees E3, E6 and E7).
Findings include:
Review of the facility policy labeled Abuse Prevention Program, states the following: the facility will require staff training/orientation programs that include such topics as abuse prevention, identification, correction of, intervention for, and reporting of abuse, exploitation and/or misappropriation of resident property, stress management, and handling verbally or physically aggressive resident behavior.
Review of E3's personnel record revealed a hire date of July 19, 2022, and lacked evidence that Employee E3 had any completed abuse training.
Review of E6's personnel record revealed a hire date of September 27, 2022, and lacked evidence that Employee E6 had any completed abuse training.
Review of E7's personnel record revealed a hire date of August 15, 2022, and lacked evidence that Employee E7 had completed abuse training.
During an interview on December 9, 2022, at 12:35 p.m. the Nursing Home Administrator confirmed that there was no evidence of completed abuse training for Employees E3, E6, and E7.
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18 (b) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based upon clinical record review, and staff interview, it was determined that the facility failed to ensure drug regimens were reviewed at least once a month and that any irregularities were acted up...
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Based upon clinical record review, and staff interview, it was determined that the facility failed to ensure drug regimens were reviewed at least once a month and that any irregularities were acted upon by a physician for four of five residents reviewed (Residents 17, 19, 62 and 105).
Findings include:
Review of Resident 17's clinical record revealed that a MRR (Medication Record Review) was completed on June 3, 2022, with a recommendation to review Trazodone/Zoloft (antidepressents) for serotonin effects. A Mrr was completed on July 10, 2022, recommendation to review a hemoglobin result from June 17, 2022. Further review of the clinical record failed to reveal that the pharmacist recommendations were addressed by the physician.
An interview with the Direcotr of Nursing on December 9. 2022, at 12:15 p.m. confirmed that the recommendations were never addressed by the physician.
Review of Resident 19's clinical record revealed that a MRR was completed on June 24, 2022, with a recommendation to review the diagnosis and usage in considering a gradual dose reduction for Seroquel (antipsychotic medication). A MRR was completed on July 24, 2022, with a recommendation to evaluate prn (as needed) Ativan (antianxiety) and to include an end date. Further review of the clinical record failed to reveal that the pharmacist recommendations were addressed by the physician. Additionally, there was no evidence that the pharmacist completed a monthly review in September 2022.
Interview with the Director of Nursing on December 9, 2022, at 11:38 a.m. confirmed that the pharmacy irregularities from June 24 and July 24, 2022 were not addressed by the physician and that there was no review for September 2022 for Resident 19.
Review of Resident 62's clinical record revealed Medication Regimen Reviews were completed on February 10, 2022, March 13, 2022, August 12, 2022 and October 16, 2022.
Interview with the Director of Nursing on December 9, 2022 at 11:40 a.m. confirmed that no further Medication Regimen Reviews were conducted for Resident 62.
Review of Resident 105's clinical record revealed that a MRR was completed on June 28, 2022, with recommendations to correct the glucagon (hormone used in controlling blood sugars) order and evaluate prn Zofran (medication used to prevent nausea and vomiting) order. A MRR was completed on July 24, 2022, with recommendation to correct Celexa (antidepressant medication) order. Further review of the clinical record failed to reveal that the pharmacist recommendations were addressed by the physician. Additionally, there was no evidence that the pharmacist completed a monthly review in September 2022.
Interview with the Nursing Home Administrator on December 9, 2022, at 10:40 a.m. confirmed that the pharmacy irregularities from June 28 and July 24, 2022 were not addressed by the physician and that there was no review for September 2022 for Resident 105.
28 Pa. Code 211.5(f) Clinical records
Previously cited 10/26/21
28 Pa. Code 211.12(c) Nursing services
Previously cited 1/12/22, 10/26/21
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 1/12/22
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation and interview, it was determined that the facility failed to ensure infection control measures were in pl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation and interview, it was determined that the facility failed to ensure infection control measures were in place during a facility COVID-19 outbreak and when community transmission levels were high on two of four nursing units observed. (Chestnut Unit and Birch Unit).
Findings include:
Upon entrance to the facility on December 5, 2022 at 6:00 a.m., PPE required usage by staff and visitors was N95 masks and face shields/goggles.
Observation of the Chestnut Nursing Unit on December 5, 2022 at 6:40 a.m. revealed a staff person sitting at the nurses' desk wearing a surgical mask not covering the nose. This same staff person was observed walking throughout the unit wearing the surgical mask not covering the nose and not wearing an N95 mask or face shield/goggles.
Observation of the Chestnut Nursing Unit on December 5, 2022 at 7:14 a.m. revealed another staff person walking room to room offering coffee and inquiring whether residents were going to the dining room. This staff person was wearing a surgical mask and not an N95 mask or face shield/goggles.
Observation of the Chestnut Nursing Unit on December 5, 2022 at 7:16 a.m. revealed a NA (nurse aide) entering resident room [ROOM NUMBER] wearing a surgical mask below the nose and not wearing an N95 or face shield/goggles.
Observation of Chestnut Nursing Unit on December 5, 2022 at 7:54 a.m. revealed a therapy staff person enter room [ROOM NUMBER] and exit into the hallway wearing a surgical mask.
Observation of Chestnut Nursing Unit on December 5, 2022 at 8:02 a.m. revealed two transport attendants arrived in the building to transport a resident to an appointment. Neither of the two attendants were wearing a face mask or face covering of any kind and were not screened at the entrance.
Observation of the Birch Nursing Unit on December 6, 2022 at 12:46 p.m. revealed a physician sitting at the nurses' station wearing a surgical mask.
Interview with family member of resident on December 8, 2022 at 11:35 a.m. revealed the family member not wearing any face mask. Family member stated that they have visited the facility on numerous occasions and never wear a face mask. The interview also revealed that the family member has not been stopped or questioned regarding PPE requirements upon entrance or by any staff persons during their visits.
Interviews with the Nursing Home Administrator on December 5, 2022 and December 9, 2022 at 1:00 p.m. confirmed all staff and visitors are required to wear N95 masks and face shields/goggles throughout building.
28 Pa. Code 201.18(b)(1) Management
Previously cited 10/26/2021, 1/12/2022, 9/14/2022
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical records review, and interviews with residents and staff, it was determined that the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical records review, and interviews with residents and staff, it was determined that the facility failed to ensure residents were free from a significant medication error for two of the three residents reviewed (Resident R1 and R2).
Findings include:
Review of Resident R1's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated October 28, 2022, revealed that the resident's cognition was intact.
Review of Resident R1's Physician order (POS) revealed the following medication orders: Gabapentin (medication used to treat nerve pain) 300 mg (milligrams) two times a day; Acetaminophen (medication to treat mild pain) 500mg given two tablets three times a day; Baclofen tablet (muscle relaxant) 5 mg every eight hours. Additional review of the physician's order revealed the following medications ordered to be administered daily at 6:00 a.m.: Anastrozole (medication used to treat breast cancer); Aspirin (anti-inflammatory medication); Metformin (medication to treat high blood sugar); Metoprolol (medication for high blood pressure); Oxybutynin (used as a bladder relaxant); Protonix (medication used to treat acid reflux); and Sertraline (anti-depressant medication).
Interview with Resident R1 on November 17, 2022, at 10:30 a.m., revealed that on November 15, 2022, her/his 6:00 a.m., medications were not administered until 10:30 a.m., only after she/he requested the nurse to give provide medications to her/him. The resident reported that she/he was not provided an explaination for why the medications were not administered timely.
Review of the November 2022, Medication Administration Record (MAR) revealed that Resident R1's medications ordered to be administered at 6:00 a.m., on November 15, 2022, were not administered.
Interview with the Director of Nursing and Nursing Home Administrator was conducted on November 17, 2022, at 1:00 p.m. The facility was unable to provide an answer to why Resident R1's 6:00 a.m., medications were not administered timely.
Review of Resident R1's Minimum Data Set, dated [DATE], revealed that the resident's cognition was intact.
Review of Resident R2's POS revealed an order for Metformin 500 mg one tablet two times daily with meals. An additional review of the POS revealed the following medications ordered to be administered at 8:00 a.m.: Calcium Carbonate (supplement); Furosemide (water pill); Irbesartan and Toprol (Medications to treat high blood pressure).
Observation conducted on November 17, 2022, at 10:05 a.m., revealed Resident R2 was in a wheelchair in front of the nursing station, wearing a jacket, shoes, and a head bonnet. The resident was heard telling the staff in the nursing station that she/he needed her morning medications. Resident R2 was heard saying Please, I need my medications, the transportation is about to pick me up and I still have not received my medications. Employee E3 was observed approaching Resident R2 and administered the resident's medication at 10:07 a.m.
Interview with licensed nurse Employee E3 was conducted on November 17, 2022, at 10:10 a.m. Employee E3 confirmed that Resident R2's scheduled 8:00 a.m., medications were not administered until 10:07 a.m. The nurse reported being an agency nurse, she/he also reported that medications were not given in timely because she/he came late to the facility and was not able to start medication administration until 8:45 a.m.
Interview with Resident R2 on November 17, 2022, at 2:00 p.m., confirmed resident did not receiving her/his scheduled morning medications until 10:07 a.m., after asking for the staff to give the medication to her/him. The Resident also confirmed that she/he already had breakfast around 9:00 a.m.
Interview with the Nursing Home Administrator (NHA) and Director of Nursing confirmed medications were not given on time because the agency nurse was late. The NHA reported that the night shift nurse stayed and took the resident's blood sugar, but oral medications were not administered.
The facility failed to ensure Resident R1 and R2 were free from a significant medication error.
28 Pa. Code 201.18(b)(1) Management
Previously cited 9/14/22, 1/12/22, 10/26/21
28 Pa. 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/14/22, 1/12/22, 10/26/21
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s), $42,912 in fines. Review inspection reports carefully.
- • 37 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $42,912 in fines. Higher than 94% of Pennsylvania facilities, suggesting repeated compliance issues.
- • Grade F (20/100). Below average facility with significant concerns.
Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Newport Meadows Center's CMS Rating?
CMS assigns NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Newport Meadows Center Staffed?
CMS rates NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 53%, compared to the Pennsylvania average of 46%. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Newport Meadows Center?
State health inspectors documented 37 deficiencies at NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER during 2022 to 2025. These included: 3 that caused actual resident harm and 34 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Newport Meadows Center?
NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by IMPERIAL HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 139 certified beds and approximately 129 residents (about 93% occupancy), it is a mid-sized facility located in CHRISTIANA, Pennsylvania.
How Does Newport Meadows Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (53%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Newport Meadows Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Newport Meadows Center Safe?
Based on CMS inspection data, NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Newport Meadows Center Stick Around?
NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER has a staff turnover rate of 53%, which is 7 percentage points above the Pennsylvania average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Newport Meadows Center Ever Fined?
NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER has been fined $42,912 across 5 penalty actions. The Pennsylvania average is $33,508. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Newport Meadows Center on Any Federal Watch List?
NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.