HILLCREST CENTER
For profit - Limited Liability company
180 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
65/100
#181 of 653 in PA
Photo by Hillcrest Center
Photo by Hillcrest Center
Photo by Hillcrest Center
1 / 10 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Hillcrest Center in Wyncote, Pennsylvania has a Trust Grade of C+, which indicates it is slightly above average in quality. It ranks #181 out of 653 facilities in Pennsylvania, placing it in the top half, and #22 out of 58 in Montgomery County, meaning only one other local facility is better. The facility is improving, with issues decreasing from 8 in 2024 to 7 in 2025. Staffing is a concern, receiving a 2/5 star rating, but has a low turnover rate of 34%, which is better than the state average. On the positive side, there have been no fines reported, indicating compliance with regulations. However, there are notable weaknesses. A serious incident occurred where a resident received the wrong food, leading to a choking episode that required CPR. Additionally, the facility failed to notify the Long Term Care State Ombudsman about certain discharges, which could raise concerns about communication and oversight. There were also issues with infection control practices observed, indicating room for improvement in maintaining safety standards. Overall, while Hillcrest Center has strengths in certain areas, families should consider these serious concerns when researching this nursing home.
- Trust Score
- C+
- In Pennsylvania
- #181/653
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 34% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 27%
Needs review
8 → 7 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 7 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Pennsylvania average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 34%
12pts below Pennsylvania avg (46%)
Typical for the industry
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
1 actual harm
May 2025
7 deficiencies
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 F0805
(Tag F0805)
A resident was harmed · This affected 1 resident
Based on review of clinical records, facility policy, dietary guidelines, and interview with staff, it was determined the facility failed to ensure Resident R369 was provided food items congruent with...
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Based on review of clinical records, facility policy, dietary guidelines, and interview with staff, it was determined the facility failed to ensure Resident R369 was provided food items congruent with his/her dysphagia diet. This failure resulted in actual harm to Resident R369 who was able to obtain food items incongruent with his/her dietary restrictions, experienced a choking episode, requiring Cardio Pulmonary Resuscitation (CPR), and transfer to the hospital for one of 33 reviewed (Resident R369).
Findings include:
Review of the facility provided guidelines, Diet and Nutritional Care Manual Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet revealed This diet is used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Food should be prepared according to individual tolerance to the food. Any food that are very hard, sticky, chewy, or crunchy should be avoided . Food allowed Grains (Low-fat as appropriate) well moistened biscuits, breads, muffins, pancakes, waffles, etc. (moistened with syrup , jelly, margarine or butter as appropriate for the diet) .
Review of facility policy titled Person-Centered Care Plan, revised on October 24, 2025, indicated the purpose is to attain or maintain the patient's highest practicable physical, mental and psychosocial wellbeing, and to promote positive communication between patient, patient representative, and team to obtain the patient's and resident representative input into the plan of care, ensure effective communication, and optimize clinical outcomes.
Review of R369's clinical record revealed the resident was admitted to facility on September 28, 2017, with medical history of Vascular Dementia (progressive degenerative disease of the brain), Schizophrenia (mental disease characterized by loss of reality contact), Dysphagia (difficulty swallowing), Anxiety, contracture of left upper extremity, Stroke, and behavioral disturbances.
Review of Resident R369's annual Minimum Data Set (MDS- assessment of resident's needs), dated February 6, 2025, indicated the resident was assessed with short and long term cognitive impairment, the resident had poor appetite or overeating and required set up with eating.
Review of Resident R369's care plan initiated January 31, 2019 revealed I am at risk for impaired swallowing related to CVA (cardio vascular accident-stroke). Interventions included a dysphagia puree, nectar thick liquids set up supervision all meals. Encourage resident to be seated with other residents who have a similar diet consistency when food is being served. Provide assistance during all meals. Resident will be at 90 degrees upright position/out of bed when swallowing food or drink. Encourage small sips/bites and cue as needed (inititiated April 28, 2022). Monitor for sign/symptoms of aspiration i.e. coughing,watery eyes, choking, moist sounding voice, daily lung checks (inititiated April 28, 2022) and if coughing occurs no food or liquids until coughing resolves.
Continued review of Resident R369's care plan revealed a care plan inititiated June 27, 2022 for restorative swallowing. [Resident R369] demonstrates difficulty with swallowing CVA with interventions developed as the resident to consume meals safely without signs and symptoms of aspiration.
Continued review of the resident's care plan revealed care plan developed on October 17, 2017, for the resident exhibiting or had the potential to exhibit physical behaviors related to cognitive loss/dementia. Interventions updated on February 18, 2019, included for the resident to maintain a safe distance from other residents during group activities and resident was not to eat meals within arms length of other residents.
Review of Resident R369's speech therapy discharge recommendations, completed by speech therapist, Employee E8, on March 6, 2025, at 10:34 a.m., revealed under strategies slow rate of intake, small bites/sips, alternate solids/liquids.
Review of Resident R369's April 2025 physician orders revealed an order for advanced dysphagia and nectar thick liquid diet.
Review of Resident R369's clinical record revealed that on April 20, 2025, at 3:15 p.m., in dining room on first floor unit, Resident R369 showed signs and symptoms of choking. The Heimlich maneuver (first aide method for choking) was initiated and expelling bolus of undigested and unidentified food. Upon further assessment, resident became pulseless, and CPR (Cardio Pulmonary Resuscitation) was initiated.
Review of Resident R369's investigation report dated April 20, 2025, confirmed the resident was in the dining room for an Easter event, received a snack per the resident dysphagia advanced diet, with resident then impulsively grabbed a snack from a tray which was being passed to other residents. Resident began to choke, staff present in the dining room responded. The nurse aide called for nurses and nurses started Heimlich, a code was called and the nursing staff continued CPR and Heimlich. Pulse was 68 BPM (beats per minute - normal pulse 60 to 100 beats per minute) to no pulse and 78% SPO2 (saturation oxygen rate- normal 95%-100%). EMS (Emergency Medical services) was called and responded and were able to get a pulse and obtained blood presure. The EMS took the resident to the ER (Emergency Room).
Review of written statement of nurse aide, Employee E11 revealed I came into the dining room around 3:15PM. We had special snacks for the resident for the holiday. I had a tray of hot dogs, about 1/2 inch long, that I was passing around for the resident. I knew [Resident R369] was not able to get them so I gave [resident] an Oatmeal Cream Pie. [Resident] ate it. As I passed (his/her) seat, (he/she) grabbed a small hot dog from the tray and shoved it down (his/her) mouth. I did not leave the tray unsupervised and I did not take my eyes off it. He started making a noise like (he/she) was choking. I immediately tried to open (his/her) mouth and take it out but (he/she) fought me and refused to open (his/her) mouth but I got it open and I placed my finger inside (his/her) mouth and removed about 1/2 inch piece of the hot dog. I yelled to the nurse who was also in the DR (dining room) with me.
Review of Resident R369's hospital documentation dated April 21, 2025, revealed patient was intubated on the scene by EMS (Emergency Medical Services), and they noted copious amount of food in patient's airway. Patient underwent 10-15 minutes of ACLS (cardiovascular life support), received epinephrine x 2, and return of spontaneous circulation (ROSC) was achieved.
Further review of hospital documentation revealed resident presented with status post out of hospital cardiac arrest secondary to aspiration of food, acute respiratory failure on vent secondary to above, bilateral pneumonia (an infection of the airsacs in one or both lungs) secondary to above, rib fractures on the left secondary to CPR .
Review of hospital dietitian/nutrition documentation, dated April 21, 2025, indicated Resident R369 presented to hospital after choking, cardiac arrest at nursing home. Pt (patient) was intubated at scene, large food bolus removed during intubation.
Interview with Licensed nurse, Employee E10, on May 1, 2025, at 10:40 a.m., revealed that she was one of the nursing employees who responded to the code on April 20, 2025, during Resident R369's choking incident. Per Employee E10's statement - during intubation process, a mushy white creamy and brownish substance was expelled. Employee E10 further stated the food substance did not have consistency of hot dog and that she was not made aware of this resident choking on a hot dog.
Further interview with Licensed nurse, Employee E10 revealed Resident R369 has a history of eating too fast and impulsively grabbing food from other residents' meal trays.
The facility failed to ensure Resident R369 was provided food items consistent with his/her dysphagia diet. This failure resulted in actual harm to Resident R369 who was able to obtain foods inconsistent with dietary restrictions, and care plan interventions who then experienced a choking episode requiring CPR, and transferred to the hospital for evaluation and treatment (Resident R369).
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 211.10(c) Resident care policies
28 Pa Code 211.12(c)(d)(1)(3) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on interview with resident and staff, review of facility provided documentation, and review of clinical record, it was determined that facility did not provide reasonable accommodations related ...
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Based on interview with resident and staff, review of facility provided documentation, and review of clinical record, it was determined that facility did not provide reasonable accommodations related to phone services for one of 33 residents reviewed. (Resident R149)
Findings include:
Review of facility policy 'Resident Right's: Role of Social Services,' revised on February 16, 2024, indicates that purpose of policy is to assure that patient's personal dignity, psychosocial well-being, and self-determination are maintained.
Review of Resident R149's Minimum Data Set, completed on February 6, 2025, indicates that resident's BIMS (Brief Interview for Mental Status) is score 8.
Review of R149's clinical record, on Wednesday, April 30, 2025, revealed medical history of Alzheimer's disease (progressive degenerative disease of the brain), fluency disorder (trouble speaking in a fluid or flowing way), depression (major loss of itnerest in pleasurable activities), and cognitive communication deficit.
Interview with Resident R149 on Tuesday, April 29, 2025, at 11:30 am, revealed that she was not able to make or receive calls from phone in her room provided by facility.
Observations of Resident R149's room environment revealed no evidence of instructions or reminders on how to accurately dial a phone number.
Interview with Resident R149's nurse aide, Employee E5, on April 29, 2025, at 11:50 am, revealed that #9 is to be dialed prior to dialing phone number and that her reminder post was most likely taken off by resident.
Interview with Resident R149 on Wednesday, April 30, 2025, indicated continuous concern that resident was unable to receive phone calls.
Per interview with Resident R149's charge nurse, Employee E4, on Wednesday, April 30, 2025, as well as review of facility provided documentation - it was revealed that inaccurate phone number was assigned to Resident's R149 room phone.
28 Pa Code 201.29(a)Resident Rights
28 Pa Code 211.10(d)Resident care policies
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the inter...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the interdisciplinary care team failed to update or revised the care plan for activities of daily living for one of two residents reviewed. ( Resident R90)
Findings include:
Review of the policy titled Center Policies and Operations revealed that it was the interdisciplinary care teams' responsibility to revise and implement a care plan for each resident. The care plan was developed for each resident to attain their highest practicable physical, mental and psychosocial well being. The care plan for each resident was to indicate any services and treatments to be administered for the resident to achieve measurable goals of care.
Clinical record review for Resident R90 revealed a quarterly assessment dated [DATE] that indicated this resident was cognitively impaired, and had bilateral upper and lower extremity impairments. The assessment indicated that this resident used a wheel chair for mobility and required maxium assistance provided by staff, for transfers from the chair to the bed and bed to the chair.
Interview with the licensed practical nurse, Employee E4 at 11:00 a.m., on May 1, 2025 revealed that Resident R90 had been refusing to get out of bed for a shower or to participate in activities over the last three months. The licensed practical nurse, Employee E4 also mentioned during the interview that Resident R90 has a sister who lives in the facility on the third floor. The licensed practical nurse was planning to invite his sister to a group activity where both resident would be out of bed and socializing with each other as they did in the past.
A review of Resident R90's activities of daily living care plan revealed that it was dated February 24, 2025. through March 3, 2025. Resident R90 had no current care plan revision and implementation to reflect a care plan for resident participation in activities and for refusal of showers.
Interview with the Director of Nursing, Employee E2, at 10:00 a.m., on May 2, 2025 confirmed the lack of care planning for Resident R90.
28 Pa. Code 211.10(d) Resident care polices
28 Pa. Code 211.12 (c)(d)(1) Nursing services
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 observations of care and services, clinical record reviews, and interviews with staff, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of care and services, clinical record reviews, and interviews with staff, it was determined that the facility failed to ensure that a physician's order was obtained, for the use of resident care adapted equipment for one of two residents reviewed. (Resident R151)
Findings iclude:
Review of Resident R151's quarterly Minimum Data Set (MDS- assessment of resident's needs) dated April 22, 2025 revealed that the resident only sometimes responded adequately to simple directions and had severe cognitive impaired. Continued review of the MDS revealed that the resident was functionally impaired on one side with the upper body extremity (shoulder, elbow, wrist and hand) and totally dependent on staff assistance for eating, personal hygiene and putting on and taking off foot wear.
Clinical record review indicated that Resident R151 had diagnoses that included: left hemicraniectomy (brain surgery that removes part of the brain to reduce swelling), left sided hemiplegia (weakness to one side of the body) and aphasia (difficulty speaking and trouble understanding). Observations of Resident R151 throughout the days of the survey April 29, 30 and May 1, 2025 revealed that this resident was resting in bed. Observations with Employee E4, licensed practical nurse at 10:30 a.m., on May 2, 2025 of Resident R151's wardrobe and personal belongings confirmed resident care equipment of a (helmet with a buckle chin strap).
Review of Resident R151's clinical record revealed that there was no documentation to indicate that the nursing staff obtained a physician's order for the use of adaptive resident care equipment (helmet with [NAME] chin strap) for Resident R151, when she was out of bed to the wheel chair.
Interviews with licensed practical nurse, Employee E13 at 10:00 a.m., on April 30, 2025 revealed that Resident R151 wears a helmet when out of bed sitting in the wheel chair. This nurse reported that nursing staff will apply the helmet to the resident's head and secure the chin strap.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide cultur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of 33 residents sampled (Resident R 73)
Findings include:
A review of the clinical record revealed that Resident R73 was admitted to the facility on [DATE], with diagnoses panic disorder (episodic paroxysmal anxiety), anxiety disorder, major depressive disorder (loss in pleasurable activities), post-traumatic stress disorder (PTSD), dementia (progressive defenerative disease of the brain), psychotic disturbance, mood disturbance and anxiety.
Interviewed with Social Worker, Employee E12 on May 2, 2025, at 11:47 a.m., revealed that the Resident R73's PTSD triggers is unknown by facility.
Resident R73's current care plan on February 3, 2025, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization.
Interview with the Social Worker, Employee E12, on May 2, 2025, at 11:50 a.m. confirmed that Resident R73 care plan for PTSD did not include resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization.
28 Pa. Code 211.12(c)(d)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on interview with staff and review of facility provided documentation, it was determined facility did not notify Long Term Care State Ombudsman of facility-initiated discharges for two of six mo...
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Based on interview with staff and review of facility provided documentation, it was determined facility did not notify Long Term Care State Ombudsman of facility-initiated discharges for two of six months reviewed. (November 2024 and December 2024)
Findings include:
Review of facility policy 'Discharge and Transfer,' revised on March 24, 2025, indicates that copies of notices for emergency transfers must also be sent to the ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirements.
Review of facility provided documentation revealed that facility's Social Services, Employee, E9, e-mailed long term care ombudsman on February 3, 2025 at 12:15 pm - forwarding monthly discharges from November 2024 - January 2025 stating I have been sending the discharges to another e-mail address which kept bouncing back.
Review of e-mail response from Long Term Care Ombudsman on February 3, 2025, at 12:24 pm, revealed that only January 2025 and February 2025 notices are acceptable at this point and anything earlier, there's not much we can do for the resident. Please forward notices on monthly basis.
28 Pa Code 201.14(a)Responsibility of licensee
28 Pa Code 201.18(b)(2)Management
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 on observations, interview with staff and review of facility provided documentation, it was determined that facility did n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview with staff and review of facility provided documentation, it was determined that facility did not ensure to maintain infection control and prevention practices on one of three units observed (1st floor unit)
Findings include:
Review of facility policy 'Standard Precautions,' revised on May 1, 2024, instructs employees to handle, transport, and process soiled, used linen in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other individuals and the environment.
Review of facility policy 'Enhanced Barrier Precautions, (EBP's) revised on December 16, 2024, indicates that EBP's are an infection control intervention designed to reduce transmission of novel or multi-drug-resistant organisms. It employs targeted personal protective equipment (PPE) use during high- contact patient/resident activities.
Observations on 1st floor unit, on Wednesday, April 30, 2025, at 9:30 a.m., revealed nurse aide, Employee E6, collected soiled personal laundry from residents' in room [ROOM NUMBER], and transferred soiled personal belongings in three mesh bags by dragging the bags on floor of the unit's hallway to soiled utility room.
Review of Resident R8's clinical record on Wednesday, April 30, 2025, revealed a [AGE] year old resident with history of colonized methicillin - resistant staphylococcus aureus (MRSA) and is at risk for sepsis.
Review of R8's care plan, revised on February 12, 2025, further revealed interventions for EBP's; Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g.central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing)
Observations on 1st floor unit, on Wednesday, April 30, 2025 at 9:15 am, revealed EBP sign in place in Resident R8 without PPE available to staff.
Findings confirmed with units charge nurse, Employee E4 at thet time of the observation.
28 Pa Code 211.10(d) resident care policies
28 Pa Code 211.12(d)(5) nursing services
Jul 2024
8 deficiencies
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 review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure medications were administered per physician orders for one of 34 residents r...
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Based on review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure medications were administered per physician orders for one of 34 residents reviewed (Resident R68).
Findings Include:
Review of Resident R68's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 28, 2024, revealed the resident was cognitively intact and had a diagnosis of urinary tract infection (an infection in any part of the urinary system) in the last 30 days.
Review of Resident R68's comprehensive care plan revised August 30, 2023, revealed the resident was at risk for alterations in comfort related to impaired mobility and skin breakdown. Interventions included to medicate resident as ordered for pain.
Further review of Resident R68's comprehensive care plan revised March 14, 2024, revealed the resident had a history of urinary tract infection and was at risk for sepsis.
During an interview with Resident R68 on July 26, 2024, at 2:25 p.m. the resident reported he missed doses of his Oxycodone (opioid medication used to treat moderate to severe pain) earlier in the week because the physician order was discontinued. Resident R68 reported when he requested his medication from the nurse, he was told they did not have the medication available.
Review of Resident R68's July 2024 medication administration record revealed an order for Oxycodone 10 milligrams (mg) every 12 hours [two times per day at 6:00 a.m. and 6:00 p.m.] for chronic pain with a start date of June 27, 2024, and was discontinued July 23, 2024.
Further review of Resident R68's July 2024 medication administration revealed the resident did not receive the Oxycodone at all on July 24, 2024, or in the morning on July 25, 2024. The medication was re-ordered again on July 25, 2024, and Resident R68 subsequently received the evening dose that day.
Review of Resident R68's clinical record revealed a nursing progress note date July 26, 2024, that indicated the resident's Oxycodone 10 mg every 12 hours was resumed and that the medication was missed for 2 days.
Interview with the Director of Nursing, Employee E2, on July 29, 2024, at 1:00 p.m. confirmed there was an error in the way the oxycodone was ordered, and that the resident should not have missed doses of the oxycodone.
Further review of Resident R68's July 2024 medication administration record revealed a physician order for Ciprofloxacin (Cipro - antibiotic that treats bacterial infections) 500 mg two times per day for urinary tract infection for 14 days with a start date of July 14, 2024. Review of the medication administration record revealed the order was not signed out as administered for the evening dose on 7/19/24, 7/21/24, and 7/25/24.
Interview and observation on July 29, 2024, at 1:15 p.m. with the Regional Registered Nurse, Employee E3, confirmed Resident R68 missed three doses of the antibiotic Cipro as the pills were still left in the medication bubble pack.
28 Pa. Code 211.9 (d) Pharmacy Services
28 Pa. Code 211.12 (d)(1)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a PICC (Peripherally Inserted Central Line Catheter) in accordance with professional standards of practice for one of one resident with PICC line reviewed (Resident R137).
Findings include:
Review of facility policy, Peripherally Inserted Central Line Catheter (PICC), dated August 2021 revealed that Measure circumference of upper arm before insertion as a baseline and when clinically indicated to assess for the presence of edema and possible deep vein thrombosis. Measure 10 cm above the insertion site. Measure external length of PICC catheter (catheter only-not the hub, extension set or needleless connector) at insertion, with each dressing change, and when clinically indicated if catheter dislodgement is suspected. Compare to measurement obtained at insertion.
Observation of Resident R137 on July 25, 2024, at 10:22 a.m, revealed that the resident had a right upper extremity PICC line insertion. There was documentation on the dressing to indicate the date and time the dressing last changed was July 18, 2024.
Review of clinical record for Resident R13 revealed that the resident was admitted to the facility on [DATE].
Review Resident R137's physician order dated March 29, 2024, revealed an order to Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10cm above antecubital). Notify practitioner if the external length has changed since last measurement every day shift every Friday.
A review of the treatment administration record (TAR) for the month of June 2024 indicated no documented evidence that the dressing change was completed on June 28, 2024, as ordered by the physician. Continued review of the TAR revealed that the PICC line assessment such as external catheter length and arm circumference measurement was also not completed.
A review of the treatment administration record (TAR) for the month of July 2024 indicated no documented evidence that the dressing change was completed on July 5, 2024. July 12, 2024, and July 19, 2024, and July 26, 2024, as ordered by the physician. Continued review of the TAR revealed that the PICC line assessment such as external catheter length and arm circumference measurement was also not completed for the above dates.
An interview with Director of Nursing, Employee E2, on July 29, 2024, at 1127 a.m. confirmed that that the PICC line dressing change, assessment and monitoring was not completed for Resident R137 as ordered by the physician and according to the facility protocol.
28 Pa. Code: 211.10 (c) Resident care policies
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that a medication w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that a medication was available in a timely manner for 1 out of 34 residents reviewed (Resident R135).
Findings include:
Review of the July 2024 physician orders for Resident R135 included the following diagnosis: Diabetes (a condition that affects your blood sugar levels and can cause serious complications); Obesity; Chronic Kidney Disease (a gradual loss of kidney function that can lead to kidney failure); Hypertension (high blood pressure) and Vitamin D Deficiency (a condition that occurs when the an individual doesn't have enough vitamin D, which is crucial for maintaining healthy bones, teeth, and muscles).
Continued review of the July 2024 physician orders included an order dated April 18, 2024 and monthly thereafter, for the administration a K2 Plus D3 Oral Tablet [PHONE NUMBER] MCG-UNIT (a vitamin supplement that helps support bone health by aiding calcium absorption and utilization). The orders stated that the resident is to be administered 1 tablet by mouth, one time day on Saturdays at 9:00 a.m.
During an interview with the resident on July 29, 2024 at 11:00 a.m. the resident reported that she takes Vitamin D&K and that she does not always get it like because that facility is always running out of it. The resident added that the nursing staff did not order the vitamin supplement ahead of time.
Review of the March 2024 Medication Administration Record (MAR) indicated that the resident was not administered the medication on March 2, 2024 at 4:01 p.m. The corresponding nursing note dated March 2, 2024 indicated that the medication was on back order.
March 23, 2024, the medication was documented as being on hold and was not administered. No corresponding nursing note.
March 30, 2024 the medication was documented as being on hold and was not administered. No corresponding nursing note.
April 6, 2024 the medication was not administered and there was no documented reason as to why. The box on the MAR was left blank, indicating that the medication was not administered.
April 13, 2024 the medication was documented as being on hold and was not administered. The corresponding nursing note indicated that it was on hold with the pharmacy.
The medication was discontinued for the remaining dates in April 2024 (April 20, 2024 and April 27, 2024) because it was not available from the pharmacy.
During an interview with the Director of Nursing (DON) on July 29, 2024 at 2:00 p.m. the resident's missed administrations were reviewed and was unaware as to why the medication was not available from their pharmacy for the resident to have administered on the above referenced dates.
28 Pa. Code 211.9(a)(1)(k) Pharmacy services
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12 (d)(1)(3) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that residents drug regimen was free of unnecessary drugs related to t...
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Based on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that residents drug regimen was free of unnecessary drugs related to the use of antipsychotic medication without adequate monitoring for two of five residents reviewed for drug regimen. (Resident R45 and Resident R29)
Findings Include:
Review of facility policy, Medication Management, dated January 2024, revealed that Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug In excessive dose (including duplicate drug therapy): for excessive duration; without adequate monitoring: without adequate indications for its use; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or . any combination of these reasons.
Medication management is based on the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring, and revising interventions, as warranted as well as documenting medication management steps. The attending physician plays a key leadership role in medication management by developing, monitoring, and modifying the medication regimen in conjunction with residents, their families, and/or representative(s) and other professionals and direct care staff (the IDT). In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use.
When selecting medications and non-pharmacological approaches, members of the IDT, including the resident, his or her family, and/or representative(s), participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. The facility's medication management supports and promotes: Involvement of the resident, his or her family, and/or the resident representative in the medication management process. Selection of medications(s) based on assessing relative benefits and risks to the individual resident; o Evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, in order to identify the underlying cause(s), including adverse consequences of medications; o Selection and use of medications in doses and for the duration appropriate to each resident's clinical conditions, age, and underlying causes of symptoms and based on assessing relative benefit and risks to, and preferences and goals of, the individual resident; o The use of non-pharmacological approaches, unless contraindicated, to minimize the need for medications, permit use of the lowest possible dose, or allow medications to be discontinued; and The monitoring of medications for efficacy and adverse consequences
Monitoring of Psychotropic Medications: When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences. After initiating or increasing the dose of a psychotropic medication, the behavioral symptoms must be reevaluated periodically (at 1east during quarterly care plan review, if not more often) to determine the potential for reducing or discontinuing the dose based on therapeutic goals and any adverse effects or functional impairment.
Potential Adverse Consequences: The facility assures that residents are being adequately monitored for adverse consequences such as: General: anticholinergic effects which may include flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation, constipation ? Cardiovascular: signs and symptoms of cardiac arrhythmias such as irregular heart beat or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest or arm pain, increased blood pressure, orthostatic hypotension ? Metabolic: increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gain ? Neurologic: agitation, distress, EPS, neuroleptic malignant syndrome (NMS), parkinsonism, tardive dyskinesia, cerebrovascular event (e.g., stroke, transient ischemic attack (TIA).
If the psychotropic medication is identified as possibly causing or contributing to adverse consequences as identified above, the facility and prescriber must determine whether the medication should be continued and document the rationale for the decision.
Review of physician order for Resident R45 dated July 23, 2024, revealed an order for Clonazepam Tablet 0.5 MG, 1 tablet by mouth two times a day for Anxiety.
Review of physician order for Resident R45 dated July 19, 2024, revealed an order for Trazodone Tablet 50 MG by mouth at bedtime for depression and insomnia.
Review of care plan for Resident R45 dated June 12, 2023, revealed a care plan for the use of psychotropic drugs, anxiolytic, antidepressants. Interventions included, monitor for changes in mental status and functional level and report to the physician as indicated. Monitor for continued need of medication as related to behavior and mood.
Review of clinical record revealed no evidence that the facility conducted ongoing monitoring of the side effects, adverse consequences, and efficiency of anxiolytic and antidepressant medication Resident R45 used.
Review of physician order for Resident R29 dated April 18, 2024, revealed an order for Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 750 MG tablet by mouth at bedtime for Substance Abuse Disorder.
Review of physician order for Resident R29 dated July 3, 2024, revealed an order for Lorazepam Tablet 1 MG by mouth two times a day for Anxiety.
Review of physician order for Resident R29 dated May 21, 2024, revealed an order for Mirtazapine Tablet 30 MG 1 tablet by mouth at bedtime for Poor Appetite/Depression.
Review of physician order for Resident R29 dated April 18, 2024, revealed an order for Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for schizophrenia.
Review of physician order for Resident R29 dated April 18, 2024, revealed an order for trazodone HCl Oral Tablet 50 MG, 1 tablet by mouth in the evening for Anxiety and Schizoaffective disorder.
Review of care plan for Resident R45 dated March 4, 2022, revealed a care plan for the use of psychotropic drugs with interventions including Complete behavior monitoring flow sheet and monitor for side effects and consult physician and/or pharmacist as needed.
Review of clinical record revealed no evidence that the facility conducted ongoing monitoring of the side effects, adverse consequences, and efficiency of anxiolytic, antidepressant, and antipsychotic medication Resident R29 used.
Interview with Employee E7, Infection Preventionist, on July 26, 2024, stated residents with psychotropic drugs should have an order to monitor the side effects/adverse effects for antipsychotic medication and staff should document the findings on an ongoing basis.
28 Pa. Code 211.12(d)(1)(3) (5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, facility documentation, interview with staff, it was determined that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with PICC line ( a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) for two of four employee records reviewed. (Employee E8 and E9).
Findings Include:
Observation of Resident R137 on July 25, 2024, at 10:22 a.m., revealed that the resident had a right upper extremity PICC line insertion. There was documentation on the dressing to indicate the date and time the dressing last changed was July 18, 2024.
Review of clinical record for Resident R13 revealed that the resident was admitted to the facility on [DATE].
Review Resident R137's physician order dated March 29, 2024, revealed an order to Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10cm above antecubital). Notify practitioner if the external length has changed since last measurement every day shift every Friday.
A review of the treatment administration record (TAR) for the month of June 2024 indicated no documented evidence that the dressing change was completed on June 28, 2024, as ordered by the physician. Continued review of the TAR revealed that the PICC line assessment such as external catheter length and arm circumference measurement was also not completed.
A review of the treatment administration record (TAR) for the month of July 2024 indicated no documented evidence that the dressing change was completed on July 5, 2024. July 12, 2024, and July 19, 2024, and July 26, 2024, as ordered by the physician. Continued review of the TAR revealed that the PICC line assessment such as external catheter length and arm circumference measurement was also not completed for the above dates.
A request for PICC line care and management competency for Employee E8, Registered Nurse and E9, Registered Nurse was requested to the Director of Nursing.
Facility did not submit the PICC line care and management competency for Employee E8 and E9 during the survey.
28 Pa. Code: 211.12 (d)(1) Nursing services
28 Pa. Code: 211.12(d)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, review of facility documentation, review of clinical records, and staff inte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to establish an effective infection control program related to infection surveillance, catheter care, and use of personal protective equipment with transmission-based precautions for one of three nursing units observed (2nd floor).
Findings Include:
Review of facility policy COVID-19 revised July 1, 2024, revealed in addition to standard precautions, special contact and droplet precautions will be implemented for residents confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. Further review of facility policy revealed staff will follow the patient specific PPE signage.
Review of Infection Control Guidance: SARS-CoV-2 from the CDC website (https://www.cdc.gov /covid/hcp/infection-control) revised June 24, 2024, revealed healthcare professional who enter the room of a patient with confirmed COVID-19 infection should adhere to Standard Precautions and use a respirator with N95 filters or higher, gown, gloves, and eye protection.
Review of facility policy Procedure: Catheter revised 02/01/2023 revealed staff should secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor.
Review of facility documentation revealed Resident R30 was tested for COVID-19 on July 24, 2024, by Infection Preventionist, Employee E7. COVID-19 testing resulted the same day which revealed Resident R30 was positive for COVID-19.
Observations on July 24, 2024, at 1:15 p.m. revealed a sign on the door of room [ROOM NUMBER] that said, patient specific contact plus airborne precautions - wear N95 (respiratory protective device designed to achieve a very close facial fit and filtration of airborne particles), gown, face shield and gloves upon entering this room. Further observations revealed a bin placed right outside the room that was stocked with yellow gowns.
Further observations at 1:15 p.m. revealed the call bell for room [ROOM NUMBER] was on. Nurse aide, Employee E4, responded to the call bell and entered room [ROOM NUMBER] while only wearing an N95. The nurse aide, Employee E4, did not have any other personal protective equipment on before entering the room including a gown, face shield, or gloves.
Nurse aide, Employee E4, was observed to exit the room moments later holding Resident R30's lunch tray. Nurse aide, Employee E4, was questioned why room [ROOM NUMBER] had signs for patient specific contact plus airborne precautions, and the nurse aide was not aware.
Interview on July 24, 2024, at 1:20 p.m. with licensed nurse, Employee E5, confirmed room [ROOM NUMBER] was on transmission-based precautions (contact, droplet, or airborne isolation) due to positive COVID-19 diagnosis for Resident R30. Further interview with licensed nurse, Employee E4, confirmed staff should utilize a N95, gown, face shield, and gloves before entering the room.
Review of Resident R163's comprehensive care plan revised June 27, 2024, revealed the resident required an indwelling foley catheter due to urinary retention.
Observations on July 24, 2024, at 1:10 p.m. revealed Resident R163's catheter bag was placed directly on the floor under the bed.
Observations were confirmed on July 24, 2024, at 1:25 p.m. with licensed nurse, Employee E5, who reported the catheter bag should be kept off the floor.
Review of facility policy Infection Prevention and Control dated November 2023, revealed that The Infection Prevention and Control (IPC) module allows ongoing infection prevention surveillance by the Infection Preventionist (IP), to detect, analyze and respond to emerging trends, and incorporate best practices for antibiotic stewardship. The IPC module provides a way for front-line staff to identify isolation and precautions. Infection cases will be identified through a manual review of the 24-hour report, dashboards/diagnostic results identifying potential risk for infection, or a triggered case from an antibiotic order or infection diagnosis. The IP will manage all infection cases through the IPC module daily. Antibiotic Time Out UDAs will be completed by the nursing staff, and the IP will ensure they are scheduled and completed timely. Infection Diagnosis(es) will be managed in collaboration with the MDS coordinator/medical records and will be resolved in a timely manner to close cases The IP will complete the Infection Screening Evaluation UDA for all suspected cases ? The Infection Screening Evaluation UDA tool is designed to identify if a resident has clinical findings indicating they MEET criteria or have a SUSPECTED infection based on McGeer's or Loeb's criteria. Upon navigating to the next section, the system will identify if the criteria should be. further investigated, and a score will be generated. S the score is a case will be created in IPC. This evaluation is not meant to diagnose. Clinical findings should be reviewed with the provider.
Facility infection surveillance log from February 2024 to July 2024 revealed the following information,
Facility infection surveillance of February 2024 revealed facility monitored (tracking) infections with date of onset, type of infection, symptoms, organisms, type of antibiotic used, start date of antibiotics, precautions and infection resolved date.
Facility infection surveillance log from March 2024 to June 2024, provided during the survey, revealed that in March 2024 facility had 11 residents with infections, 10 infections did not identify an infection type (documented empty). 10 infections did not identify an organism (no documentation), No infections had signs and symptoms documented.
In April 2024, facility had 10 residents with infections, 8 infections did not identify an infection type (documented empty). 8 infections did not identify an organism (no documentation), 8 infections had no signs and symptoms documented.
In May 2024, facility had 11 residents with infections, all 11 infections did not identify an infection type (documented empty). All 11 infections did not identify an organism (no documentation), and had no signs and symptoms documented.
In June 2024, facility had 8 residents with infections, 5 infections did not identify an infection type (documented empty). 5 infections did not identify an organism (no documentation), 5 infections had no signs and symptoms documented.
Interview with Employee E7, Infection Preventionist, on July 26, 2024, confirmed that the facility infection surveillance log was incomplete from March 2024 to June 2024.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(c)(d)(1) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a ...
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Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for five of five months of antibiotic stewardship program data reviewed. (February 2024, March 2024, April 2024, May 2024 and June 2024).
Findings Include:
Review of facility policy Antibiotic Stewardship dated August 7, 2024 , revealed that Centers will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and systems for monitoring antibiotic use. The Infection Preventionist (IP) is responsible for the Infection Prevention and Control program including ASP. The Administrator is ultimately responsible for the overall compliance with the ASP. The Director of Nursing (ON) and Medical Director are responsible for executing the ASP standards.
Further review of facility policy and protocol revealed that the facility policy included CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes,
A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs.2 CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.
Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors.
Integrate the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders.
Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use
Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.
Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Some antibiotic use measures (e.g., prevalence surveys) provide a snap-shot of information; while others, like nursing home initiated antibiotic starts and days of therapy (DOT) are calculated and tracked on an ongoing basis. Selecting which antibiotic use measure to track should be based on the type of practice intervention being implemented. Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT.
Review of facility policy Infection Prevention and Control dated November 2023, revealed that The Infection Prevention and Control (IPC) module allows ongoing infection prevention surveillance by the Infection Preventionist (IP), to detect, analyze and respond to emerging trends, and incorporate best practices for antibiotic stewardship. The IPC module provides a way for front-line staff to identify isolation and precautions. Infection cases will be identified through a manual review of the 24-hour report, dashboards/diagnostic results identifying potential risk for infection, or a triggered case from an antibiotic order or infection diagnosis. The IP will manage all infection cases through the IPC module daily. Antibiotic Time Out UDAs will be completed by the nursing staff, and the IP will ensure they are scheduled and completed timely. Infection Diagnosis(es) will be managed in collaboration with the MDS coordinator/medical records and will be resolved in a timely manner to close cases The IP will complete the Infection Screening Evaluation UDA for all suspected cases ? The Infection Screening Evaluation UDA tool is designed to identify if a resident has clinical findings indicating they MEET criteria or have a SUSPECTED infection based on McGeer's or Loeb's criteria. Upon navigating to the next section, the system will identify if the criteria should be. further investigated, and a score will be generated. S the score is a case will be created in IPC
Review of facility documentation from the month of March 2024 revealed that the facility had a total of 11 antibiotic orders. All 11 of those orders did not have any symptoms documented on the facility infection surveillance tool. It was also revealed that the surveillance tool did not contain a stop date, total days of therapy, outcome and adverse events. There was no antibiotic review completed to determine the appropriateness of the antibiotic usage.
Review of facility documentation from the month of April 2024 revealed that the facility had a total of 10 antibiotic orders, 8 of those orders did not have any symptoms documented on the facility infection surveillance tool. It was also revealed that the surveillance tool did not contain, outcome and adverse events. There was no antibiotic review completed to determine the appropriateness of the antibiotic usage.
Review of facility documentation from the month of May 2024 revealed that the facility had a total of 11 antibiotic orders. All 11 of those orders did not have any symptoms documented on the facility infection surveillance tool. It was also revealed that the surveillance tool did not contain, outcome and adverse events. There was no antibiotic review completed to determine the appropriateness of the antibiotic usage.
Review of facility documentation from the month of June 2024 revealed that the facility had a total of 8 antibiotic orders. All 5 of those orders did not have any symptoms documented on the facility infection surveillance tool. It was also revealed that the surveillance tool did not contain, outcome and adverse events. There was no antibiotic review completed to determine the appropriateness of the antibiotic usage.
Interview with Employee E7, Infection Preventionist, on July 26, 2024, confirmed that the facility antibiotic stewardship program did not include use protocols for antibiotics and a system to effectively monitor antibiotic usage.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected multiple residents
Based on the review of facility provided documentation and interview with staff, it was determined that facility did not ensure to include as part of its Quality Assurance and Performance Improvement ...
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Based on the review of facility provided documentation and interview with staff, it was determined that facility did not ensure to include as part of its Quality Assurance and Performance Improvement (QAPI) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for four of five employees reviewed (Employees E10, E11, E12 and E13)
Findings include:
Review of Employee education record for Employee E10, Licensed Practical Nurse, revealed no evidence of training provided regarding facility's QAPI program.
Review of Employee education record for Employee E11, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.
Review of Employee education record for Employee E12, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.
Review of Employee education record for Employee E13, Licensed Practical Nurse, revealed no evidence of training provided regarding facility's QAPI program.
Findings confirmed with Director of Nursing on July 29, 2024.
28 Pa Code 201.14(a)Responsibility of licensee
28 Pa Code 201.18(b)(1) Management
28 Pa Code 201.20(a)(c)Staff development
Sept 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observations, interview with residents and staff, it was determined that the facility did not ensure that most recent survey results were accessible to residents on one out of three units obs...
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Based on observations, interview with residents and staff, it was determined that the facility did not ensure that most recent survey results were accessible to residents on one out of three units observed ( Unit one, First floor)
Findings include:
Group interview conducted on September 21, 2023 at 11:00 a.m., with alert and oriented Residents R81, R38, R149, R67, R100, R82, and R29 revealed that the residents did not know where the results for the most recent survey from state agency were located.
Observations of Unit one, First floor, on September 22, 2023 at 1:45 PM, revealed no evidence of most recent survey results available for residents to view. Observations of Unit three, third floor, revealed a missing sign above survey results, preventing residents from easily locating survey results.
The above findings were confirmed by Director of Nursing, Employee E2 on September 22, 2023 at 2:00 PM.
28 Pa Code 201.18(b) Management
28 Pa Code 201.18(b)(1)(3) Management
28 Pa Code 201.18(e)(1) Management
28 Pa Code 201.29(a) Resident Rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on review of facility policy and staff interview, it was determined that the facility failed to ensure that notices of Medicare non-coverage Skilled Nursing Facility Advanced Beneficiary Notice ...
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Based on review of facility policy and staff interview, it was determined that the facility failed to ensure that notices of Medicare non-coverage Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) were provided timely for two out of three residents reviewed (Residents R273 and R158)
Findings include:
The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNFABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights.
Review of Residents R273's Medicare non-coverage information indicated that Resident R273 was to receive a SNFABN. Facility documentation indicated that Resident R273 had last covered date of Part A service end on March 23, 2023. There was no evidence that Resident R47 received SNFABN.
Review of Residents R158's Medicare non-coverage information indicated that Resident R158 was to receive a SNFABN. Facility documentation indicated that Resident R158 had last covered date of Part A service end on May 3, 2023. There was no evidence that Resident R158 received SNFABN.
Interview with facility's admission representative, Employee E20 on September 21, 2023 at 1:20 p.m. revealed no evidence of knowledge of required notifications to be provided for residents who choose to remain in facility. F
28 Pa. Code 201.18(e)(1)Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for one of three nursing units observed. (Unit ...
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Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for one of three nursing units observed. (Unit one).
Findings Include:
Observation made of the first floor balcony/patio area on September 22, 2023 at 9:17 a.m. from the inside of the building from the second floor. There appeared to be a medication cart, geri-chairs, and spare wheelchairs outside being stored on the patio area.
Interview and observation made with Director of Maintenance, Employee E10 on September 22, 2023 at 9:19a.m. revealed the equipment that was currently on the patio area was all transferred outside from the facility tub rooms. When asked when the items were moved outside the Director of Maintenance, Employee E10 stated Wednesday the items were moved. When questioned why the items were moved outside the Director of Maintenance, Employee E10 stated, they were needing to get things out of the tub rooms, and with you all coming here on Wednesday it pushed them a little bit.
Observation was made on September 22, 2023 at 9:20 a.m. and there was trash on the porch area. There was a large trash can with standing water full to the top with a spare trash bag, some empty wrappers, and empty bottles floating on top of the trash can full of water.
On the patio area there was spare equipment, and broken equipment being stored. This area is located outside of the first floor dining area. On the patio area next to the facility there were six wheel chairs, two high back wheelchairs, six geriatric chairs, two laundry carts, one medication cart, and a dining room table.
Further observation of the outside patio and porch area was made on September 25, 2023 at 10:14 a.m. The porch area contained six geriatric chairs and a dining room table. The patio area still had a large trash can with standing water full to the top with a spare trash bag, some empty wrappers, and empty bottles floating on top of the trash can full of water.
28 Pa. Code 201.18(b)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and observations , it was determined that the facility did not provide appropriate care for acti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and observations , it was determined that the facility did not provide appropriate care for activities of daily living (ADL), including incontinence care and oral hygiene care for two out of 35 residents reviewed (Resident R115 and R134).
Findings include
Observations of Resident R115 on September 20, 2023 at 11:00 a.m, revealed resident laying in bed with significant oral odor noted, and complaining of staff not assisting him of mouth care during morning hygiene. Finding confirmed with nurse aide, employee E21.
Review of R115's clinical records revealed diagnosis of nontraumatic subdural hemorrhage, spastic hemiplegia (type of cerebral palsy where muscle stiffness affects one side of body), muscle weakness, contracture of left hand, wrist and elbow. According to R115's care plan, resident requires assistance/ is dependent for activities of daily living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: functional decline.
Additional review of Residents R115' Minimum Data Set (MDS) dated [DATE], revealed that Resident R115 required extensive assistance with two or more persons physical assistance for personal hygiene.
Observation of Resident R134, on September 20, 2023 at 10:40 a.m. on unit one, First floor, revealed Resident R134 laying in bed with significant urine odor noted; finding confirmed with licensed nurse, Employee E18. Per nursing report, Resident R134 was incontinent and required assistance with changing briefs.
Review of Resident R134's MDS dated [DATE], revealed that Resident R134 required supervision/oversight, encouragement or cueing as well as one person physical assistance for toilet use.
Review of Resident R134's care plan revealed that resident is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: illness, fall, hospitalization, etc. resulting in fatigue, activity intolerance, confusion.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(5)Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, resident clinical record and staff interview, it was determined that the facility failed to ensure that physician's orders were followed related to an abdominal binder to secure ...
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Based on observation, resident clinical record and staff interview, it was determined that the facility failed to ensure that physician's orders were followed related to an abdominal binder to secure a feeding tube for one of one resident review receiving eternal feeding. (Resident R54)
Findings include:
Review of Resident R54's September 2013 physician orders revealed an order for abdominal binder to be off of resident during skin assessments. Further review of physician orders revealed that skin assessments were to be conducted once a shift.
Observations of Resident R54 on September 20, 2023 at 10:30 a.m., revealed that the resident was laying in bed with enteral tube feeding line disconnected and nutrition spilled on to bed linens and two puddles of nutrition spilled on floor near residents bed. Resident's abdominal binder was off of resident and placed at foot of bed.
Surveyor brought up to the attention of Licensed nurse, Employee E18 on September 20, 2023 at 10:35 a.m. the observations made of Resident R54's as stated above. Licensed nurse, Employee E18 stated that the nurse aide and housekeeping were aware and they were going to take care ot it.
The facility failed to ensure that an abdominal binder was placed on Resident R54 to secure the tube feeding as order by the physician.
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, review of facility policy and interviews with staff, it was determined that the facility failed to provide food and drink that was palatable, attractive, and served at appetizing...
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Based on observation, review of facility policy and interviews with staff, it was determined that the facility failed to provide food and drink that was palatable, attractive, and served at appetizing temperatures on two of three nursing units. (First Floor and Second Floor)
Findings Include:
Review of facility policy titled Time and temperature control and recording. The purpose of the policy states, To educate all new hires and current employees on the importance of and guidelines for time and temperature control and recording procedures. Bacteria and other foodborne pathogens can grow quickly in the temperature Danger Zone of 41-135 degrees Fahrenheit. Proper thawing, cooking, reheating, holding, and transport of food is critical for resident safety and wellness.
Observation was made on September 22, 2023 at 11:46a.m. of food trays being prepared in the kitchen.
On September 22, 2023 at 12:14 p.m. the box cart holding the test tray left the kitchen to go to the Third floor. At 12:16 p.m. it arrived on the Third floor. At 12:27 p.m. all other food trays were passed out on the floor. At 12:28 p.m. the food tray was taken out of the box cart. The temperatures were tested for both the cold and the hot foods. The temperature of the fish at 12:29 p.m. was 132.5 degrees Fahrenheit. The milk temperature was 51.4 degrees Fahrenheit.
On September 25, 2023 at 12:05 p.m. the box cart holding the test tray left the kitchen to go to the first floor. At 12:07 p.m. it arrived on the first floor. At 12:18 p.m. the food tray was taken out of the box cart. The temperature of the egg salad served was 52 degrees Fahrenheit. The temperature of the beet salad served was 53 degrees Fahrenheit.
28 Pa. Code 210.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products broug...
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Based on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for two of three nursing units. (First floor and Second floor).
Findings Include:
Review of Facility Policy: Food: Safe Handling for Foods from Visitors revised 7/2019 states Resident will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. The procedure states, 5. Refrigerator/Freezers for storage of foods brought in by visitors will be properly maintained and: Equipped with thermometers. Have temperature monitored daily for refrigeration less than or equal to 41 degrees Fahrenheit and freezer less than or equal to 0 degrees Fahrenheit. Daily monitoring for refrigerated storage duration and discard any food items that have been stored for seven days or more. (Storage of frozen foods and shelf stable items may be retained for 30 days.) Cleaned weekly.
Observation of the nourishment closet on the Second floor was made on September 20, 2023 at 11:33 a.m. in the resident refrigerator there was a bag of takeout food for Resident R83 labeled September 10, 2023. There was a bag of takeout French fries undated and with no resident name. There was a container of prune juice that was on it's side and spilled all over the inside of the door refrigerator. There was a small opened container of orange juice undated with no resident's name.
Confirmation on the condition of the resident refrigerator was made by Licensed nurse, Employee E5 on September 20, 2023 at 12:13 p.m.
Review of the Second floor resident refrigerator's temperature log revealed that there were no documentation of the temperatures of the refrigerator on September 3, 4, 10, 16, 17, 18, and 19.
Observation on September 20, 2023 at 12:27 p.m. of the First floor's nourishment closet revealed a resident refrigerator with no temperature log. In the refrigerator was takeout food in blue bag no label. A yogurt was in a bag in freezer with no label.
Interview on September 20, 2023 at 12:32 p.m. with Director of Maintenance, Employee E10 revealed that the inside of the refrigerators would be maintained by housekeeping.
28 Pa. Code 201.18(b)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and review of policy and procedure, it was determined that the facility failed to maintain an effective infection control program related to the appropriate cleaning of medical eq...
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Based on observation and review of policy and procedure, it was determined that the facility failed to maintain an effective infection control program related to the appropriate cleaning of medical equipment on one of three nursing units. (Second floor)
Findings include:
Review of facility policy titled Infection Control Policies and Procedures - IC201 Cleaning and Disinfecting revised May 1, 2023, states that noncritical items are objects that do not come into contact with mucus membrane but do come into contact with intact skin (e.g., blood pressure cuff, glucose meters, stethoscope, activity supplies, sensory manipulatives, craft supplies). These items require cleaning between patient use.
Observations conducted during medication pass on September 20, 2023 at 9:27 a.m. with Licensed nurse Employee E15, revealed that the Dinamap (an instrument used to monitor vital signs including blood pressure, pulse rate, oxygen, and temperature ), was utilized between Resident R117 and Resident R143 without being disinfected between residents.
Observation conducted during medication pass on September 20, 2023 at 10:29 a.m. with Licensed nurse Employee E14 revealed the Dinamap was utilized on Resident R228 without being disinfected.
Observation of Licenced Nurse, Employee E5 on September 21, 2023 at 9:37 a.m. on the Second floor back hall, utilizing the Dinamap without disinfecting it before or after usage between residents.
28 Pa. Code 211.12(d)(1) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on observations of residents and activities programing, review of activities calendar, interview with staff and residents, it was determined that the facility failed to employ sufficient support...
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Based on observations of residents and activities programing, review of activities calendar, interview with staff and residents, it was determined that the facility failed to employ sufficient support staff to provide recreational programs to meet the psychosocial, emotional, and care needs on three of three nursing units.
(First, Second and Third floor)
Findings include:
Review of facility policy titled Recreation Services Policies and procedures revised April 7, 2018 states that residents have the right to participate or not participate in leisure and recreation of their choosing. Further evaluation of this policy revealed that residents will be invited to attend activities of preference and interest and will be provided the opportunity to participate in a structured and individual programs.
Observation on September 20, 2023 at 11:25 a.m. on the First-floor activities room there were 13 residents observed sitting at tables with an employee at the door to monitor. There were no activities taking place at this time.
Review of the weekly scheduled provided stated that there was bingo scheduled at 2:00 p.m. on September 21, 2023.
Observation on September 21, 2023 at 2:05 p.m. on the First-floor activities room included nine residents, Second floor activities room included 4 residents and there were no residents present in the Third floor activity room. Neither floors had any activities.
Observation on September 22, 2023 on the Second-floor activities room revealed there was no resident in the room, there was no activities happening. Per the activity schedule the resident were to be engaged in the activity Manicures.
Interview with Resident R124 revealed that there are not any activities of interest.
Interview with Activities director Employee E9, on September 20, 2023 at 1:40 p.m. a request was made for the activities calendar. Employee E9 stated that there is shortage of staffing in the activities department, consequently there was not a complete monthly calendar. Employee E9 provided weekly activities that consisted of an activity for one floor at 2:00 p.m. daily. Employee E9 stated that there are no activities on weekends due to staff shortage. Tour of the facility revealed no activities observed any time.
Interview conducted with Activities Director, Employee E9 on September 25, 2023 revealed that there were no activities on the previous day of observation due to field trip to a local department store for only a few residents. Employee E9 admits to not having activities for all resident, stating that the residents can always ask for a coloring book.
28 Pa Code 2012.18 (b)(1) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on review of facility's documentations and interview with staff, it was determined that the facility did not take actions aimed at performance improvement and after implementing those actions, m...
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Based on review of facility's documentations and interview with staff, it was determined that the facility did not take actions aimed at performance improvement and after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.
Findings include:
Review of facility's Quality Assurance Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) agenda for July 19, 2023, revealed areas of concern regarding food delivery system, room furniture/old appearance, medications in med carts (old), re-hospitalization rate, agency usage. Further review of agenda revealed 'action steps' to be taken with 'on-going' follow-up. Facility was not able to provide evidence for measuring success of suggested action plans for the areas noted above. Facility was not able to show documented evidence of tracking performance.
Review of facility's QAPI and QAA agenda for August 16, 2023, revealed areas of concern regarding food delivery system, re-hospitalizations, and recruitment/retention. Further review of agenda revealed 'action steps' to be taken with 'on-going' follow-up. Facility was not able to provide evidence for measuring success of suggested action plans for the areas noted above. Facility was not able to show documented evidence of tracking performance.
Review of facility's assessment plan dated September 9, 2022 through September 8, 2023 revealed that
B.1 Acuity - QAPI Action/Plan Summary: facility goes through all assessments on an annual basis. Any area identified as lacking will be addressed in QAPI with root cause analysis and reported on until issue is rectified. Further review of facility's assessment revealed number of admissions/stays ending in hospitalization as 'high', stays ending in death as 'high', malnutrition - 'very high', swallowing difficulty - 'very high', feeding tube - 'high.'
Review of QAPI meeting minutes for months of May 17, 2023, July 19, 2023 and August 16, 2023, revealed no evidence of facility addressing areas of concern mentioned above based on facility's assessment.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on review of facility's documentation, and staff interview, it was determined that the facility did not hold Quality Assurance Process Improvement meetings at least quarterly for one out of four...
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Based on review of facility's documentation, and staff interview, it was determined that the facility did not hold Quality Assurance Process Improvement meetings at least quarterly for one out of four quarters reviewed (first quarter, January - March 2023)
Findings include:
According to facility's framework for Quality Assurance/ Performance Improvement, committee must be comprised of director of nursing (DON), infection preventionist, medical director or designee and 3 additional team members one of which is the administrator. A consultant pharmacist is recommended to serve on the committee. This is a minimum requirement. CMS SOM states other department heads should have the opportunity to be involved as well as residents and family having vital information for the committee.
The Quality Assessment and Assurance (QAA) committee will meet ten times a year. QAA activities and outcomes will be on the agenda of every staff meeting and shared with residents and family members. Centers will define process for communication with residents and family members.
The QAA committee will have responsibility for reviewing data, suggestions, and input from residents, staff, family members, and other stakeholders. The QAA committee will prioritize opportunities for improvement and determine which performance improvement projects will be initiated. When an issue or problem is identified that is not systemic and does not require a performance improvement project
During interview with Nursing Home Administrator on September 25, 2023, it was confirmed that facility was unable to provide QAPI meeting minutes for months of January 2023 through March 2023.
Review of 'Hillcrest Center Quality Assurance and Improvement Meeting' dated May 17, 2023, revealed no pharmacy consultant present during meeting.
28 Pa Code 201.18(e)(1)(2)(3) Management
Aug 2023
5 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** Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide written notice, including reason for transfer before a resident's room was change for one of 12 residents reviewed (Resident R10).
Findings Include:
A review of facility policy titled, Room transfers revised August 7, 2023, revealed Notification of room change, or new roommate will be provided within reasonable/required time frames . If the room change is facility initiated and the patient agrees to transfer, the facility must give the resident or resident representative as much notice as possible including an explanation of the reason for the move. The facility must provide an opportunity for the resident or resident representative to see the location and meet the new roommate.
Review of Resident R10's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated June 15, 2023, revealed Resident R10 was admitted to the facility on [DATE], with diagnoses including mild cognitive impairment, cognitive communication deficit, anxiety, and depression. Review of Resident's BIMS (Brief Interview for Mental Status) revealed resident had severely impaired cognition. Resident R10's clinical record indicated that her son was her power of attorney.
Clinical record review for Resident R10 revealed a Social Services note dated August 18, 2023, at 3:43 p.m. which indicated that placed a telephone call to residents' son after speaking with resident regarding a room change, resident was made aware that a window bed is available which resident was an agreement with and so was her son.
Continued record review for resident R10 revealed another Social Services note dated August 21, 2023, at 3:43 p.m. which indicated that Resident R10's family is upset with the room change that took place on Friday 8/18/2023. Resident R10's son explained that he was not notified that the room would be at the end of the hallway, and that he would like his mother's room to be changed closer to the front as he is unable to walk a far distance.
Interview conducted on August 23, 2023, at 1:19 p.m. with Social Services Director, Employee E12, revealed that the change was initiated due to a new admission hesitated to come to a full bedded room. Further interview revealed that the social worker should have explained and documented the reason of the initiated room change prior to making the change. This interview confirmed that Resident R10 and their representative was not provided with reason of room change per policy. Employee E12 also confirmed that the resident and their representative were not provided with a chance to see the new room or meet her new roommates. Resident R10's power of attorney did not receive a written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.
Observations of Resident R10's room [ROOM NUMBER], prior to her room change, revealed Resident R10's belongings were in plastic bags on the nightstand while Resident R10 was residing in room [ROOM NUMBER].
Interview with Resident R10 conducted on August 22, 2023, at 1:57 p.m. in room [ROOM NUMBER], Resident R10 stated, I want to go home, please take me home. Resident was observed crying, shaking, and emotionally upset.
Interview with Unit Manager, Employee E13, on August 22, 2023, at 3:00 p.m. confirmed that Resident R10 was not transferred prior to this transfer dated August 18, 2023.
28 Pa. Code 201.14(a) Responsibility of licensee
29 Pa. Code 201.29(d) Resident rights
29 Pa. Code 201.29(j) Resident rights
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
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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to deve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for two of 12 residents reviewed. (Resident R10, R1)
Findings include:
Review of facility policy titled, Person- Centered Care Plan revised October 24, 2022, revealed that the Care plan will be created for each resident to attain or maintain the patient's highest practicable physical, mental and psychosocial wellbeing and to To eliminate or mitigate triggers that may cause re-traumatization of the patient. The care plan must be customized to each individual patient's preferences and needs.
Review of Resident R10's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated June 15, 2023, revealed Resident R10 was admitted to the facility on [DATE], with diagnoses including mild cognitive impairment, cognitive communication deficit, anxiety, and depression. Review of Resident's BIMS (Brief Interview for Mental Status) revealed resident had severely impaired cognition. Resident R10's clinical record indicated that her son was her power of attorney.
Clinical record review for Resident R10 revealed a Social Services note dated August 18, 2023, at 3:43 p.m. which indicated that placed a telephone call to residents' son after speaking with resident regarding a room change, resident was made aware that a window bed is available which resident was an agreement with and so was her son.
Continued record review for resident R10 revealed another Social Services note dated August 21, 2023, at 3:43 p.m. which indicated that Resident R10's family is upset with the room change that took place on Friday 8/18/2023. Resident R10's son explained that he was not notified that the room would be at the end of the hallway, and that he would like his mother's room to be changed closer to the front as he is unable to walk a far distance.
Interview conducted on August 23, 2023, at 1:19 p.m. with Social Services Director, Employee E12, revealed that the change was initiated due to a new admission hesitated to come to a full bedded room. Further interview revealed resident was very upset with her new room.
Interview with Resident R10 conducted on August 22, 2023, at 1:57 p.m. Resident R10 stated, I want to go home, please take me home. Resident was observed crying, shaking, and emotionally upset.
Review of Resident R10's clinical record revealed no documented evidence a comprehensive care plan was developed for Resident's R10 regarding resident had difficult time adjusting to her new room status post room change.
During and interview with Resident R1 conducted on August 21, 2023, at 10:10 a.m. resident stated, I prefer a vegetarian diet. Further interview revealed she followed a vegetarian diet since admission. Resident R1 stated she had voiced her preferences to the Registered Dietitian upon admission.
Review of Resident R1's Quarterly MDS dated [DATE], revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including dysphasia (difficulty to swallow), gastroparesis (a disorder that slows or stops the movement of food from your stomach to your small intestine), and gastroesophageal reflux disease (a condition in which the stomach contents move up into the esophagus). Review of Resident's BIMS revealed resident was cognitively intact.
Review of Resident R1's clinical records revealed a note by the Registered Dietitian on July 24, 2020, which indicated that resident was in fact following a vegetarian diet, Selects meals and prefers to Vegetarian diet usually. Another note by the Registered Dietitian on November 16, 2022, revealed that the resident received the preferred Vegetarian burger with vegetables but stated to writer I always get this and fish.
Review of Resident R1's clinical record revealed no documented evidence a comprehensive care plan was developed for Resident's R1 regarding her preference of eating a vegetarian diet.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
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 F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observations of the Food and Nutrition Services, reviews of policies and procedures, and interviews with residents, it was determined that the facility failed to ensure that each resident rec...
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Based on observations of the Food and Nutrition Services, reviews of policies and procedures, and interviews with residents, it was determined that the facility failed to ensure that each resident received foods and beverages that were at appetizing temperatures.
Findings include:
Review of the facility policy titled, Time and Temperature Control and Recording revised September 2017, revealed, bacteria and other foodborne pathogens can grow quickly in the temperature Danger Zone of 41-135 degrees Fahrenheit . Proper holding and transport of food is critical for resident safety and wellness. Further review, under the section titled Transporting, revealed, that all hot foods must be maintained at 135 degrees Fahrenheit or above and that all cold foods are maintained at 41 degrees Fahrenheit to minimize opportunities for bacterial growth.
Observations of the tray line conducted on August 21, 2023, at approximately 1:00 p.m. revealed the salad container was not cooled/iced on the tray line to maintain proper cold holding procedures and ensure food safety.
On August 21, 2023, at 1:30 p.m. a Test Tray was conducted in the presence of the Assistant Food Service Manager, Employee E7, which revealed that the temperatures of the cold foods tested were in the Danger Zone of 41-145 degrees Fahrenheit.
The ham and cheese sandwich registered at 62.4 degrees Fahrenheit; lettuce and tomato at 64 degrees Fahrenheit; fruit cocktail at 56.3 degrees F; and juice at 43.9 degrees Fahrenheit.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 211.6(f) Dietary services
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, review of clinical records, review of facility policy and staff interview, it was det...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 12 residents reviewed (Resident R12).
Findings Include:
A review of facility policy titled, Elopement of Patient revised September 24, 2022, indicated that all Elopement Risk Identification forms for residents at risk of elopement must be current. Residents will be evaluated for elopement risk with change in condition. The elopement investigation to be completed within five days.
Review of the Facility Elopement Investigation Report, dated, August 10, 2023, indicated that Resident R12 was observed by the supervisor ambulating independently outside in the front of the building. Resident is severely cognitively impaired, identified as an elopement risk with wanderguard in place and functioning . Upon return to her room staff noted that the window screen was pushed out & the window open approximately 10. Resident weight is 80 pounds. Window was closed & secured; the maintenance director checked the window & identified the stop brackets to be bent & loose allowing the window to open to 8-10. Per maintenance director it appeared the window was forced up causing the brackets to bend.
A review of Resident R12's Comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 7, 2023, revealed the resident was admitted on [DATE], and had diagnoses including Alzheimer's Dementia (range of conditions that affect the brain's ability to think, remember, and function normally).
Further review of Resident R12's clinical records revealed an Elopement Evaluation with a start date of August 11, 2023, at 9:30 a.m. The Elopement Evaluation for Resident R12 was completed and signed during the abbreviated complaint survey on August 21, 2023, at 11:40 a.m.
A review of facility nursing assignments dated August 10, 2023, through August 11, 2023, for all three shifts revealed that Nurse Assistant, Employees 15, 16, 17, and 21 were assigned to Resident R12 and provided direct care.
Continued review of the Facility Investigation Report failed to reveal written statements from nurse aides who provided direct care to Resident R12 on August 10 and August 11, 2023.
During the exit meeting conducted on August 22, 2023 at approximately 4:40 p.m. the Nursign Home, Administrator, Director of Nursing, and Assistant Director of Nursing confirmed the above-mentioned findings.
28 Pa Code 211.5(f) Clinical records
28 Pa Code 211.12(d)(1) Nursing services
CONCERN
(E)
📢 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 multiple residents
Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to two dining rooms obs...
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Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to two dining rooms observed. (First Floor and Second Floor dining rooms.)
Findings include:
Review of facility policy titled, Resident Rights Under Federal Law revised February 1, 2023, indicated that the facility must treat each resident with respect and dignity and care for each resident in a manner and an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth.
Interview with Resident R1 on August 21, 2023, at 10:10 a.m. revealed meals do not arrive timely and that residents were not served at one time, you just sit there and watch someone else eat.
Observations of the First-floor dining room on August 21, 2023, at 12:15 p.m. revealed the following:
A table of three residents, only one resident was served a meal.
Further observations revealed a resident walked into the dining room to be seated and was told there was no more room available for her to sit. Employee E14 stated, someone will get up soon, come back a little later.
Interview held with the Speech Pathologist, Employee E14, at 12:20 p.m. confirmed that the first-floor dining room never has enough room to seat all residents.
Observations of the second-floor dining conducted on August 21, 2023, at 12:35 p.m. revealed the following:
A table of two residents; one resident was served a meal at 12:37 p.m. This resident ate his meal and left the dining room at 12:49 p.m. The second resident received his meal seventeen minutes later, at 12:54 p.m.
A table of three resident; one resident was served a meal at12:37 p.m.; another resident was served at 12:47 p.m.; the last resident was served at 12:54 p.m.
Further observations revealed Resident R11 attempting to leave the dining room. Interview with resident R11 at 12:43 p.m. revealed lunch meals never come on time and it's worse now.
Interview with the Food Service Department team on August 21, at approximately 3:00 p.m. confirmed the above-mentioned findings.
28 Pa. Code 201.29(d) Resident Rights
May 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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and staff interview, it was determined the facility failed to maintain an enviro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and staff interview, it was determined the facility failed to maintain an environment that was safe and sanitary for residents in one of two nursing units (Third Floor nursing unit).
The findings include:
Review facility policy named IC201 Cleaning and Disinfecting revised May 1, 2023 revealed Cleaning and disinfecting of frequently touched items and surfaces, patient/resident (hereinafter patient) care items and the environment, including common area of the Center, will be conducted routinely and based on risk of infection involved.
Observations conducted in the company of Licensed nurse, Employee E6 on May 4, 2023, at 12:02 a.m. revealed the following:
- room [ROOM NUMBER] had a tower bar missing in the bathroom for B bed; the entire room had sticky floors and smelled like urine; four resident's drawers had chipped wood in different areas of the drawer. The left side of the wall at the entrance of the room by A bed had a broken off baseboard. [NAME] spots were observed behind A bed. The Dresser for B -bed had chipped off wood.
-The hallway between room [ROOM NUMBER]-329 had a strong urine smell; urine spots were observed on the carpet across from room [ROOM NUMBER].
-room [ROOM NUMBER]-B had a strong urine smell. Resident of B bed was located by the window and the window was open circulating the air, but even with a fresh air circulation the urine smell was significant. Employee E6, nursing manager reported that a resident who resided in the room had an indwelling catheter and that residents with urinary catheters had a stronger urine smell in the rooms.
- A strong smell of feces and urine was noted in room [ROOM NUMBER]. Interview with the housekeeping staff, Employee E11 at the time of the observation revealed that the reason why there is a strong smell is due to the mattress belonging to the resident residing in C bed being soiled with urine. Employee E11 stated that the resident who reside in C bed is using a urinal and spills and it contributes to the smell.
28 Pa. Code: 207.2(a) Administrator's responsibility
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
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- • 34% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • 32 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Hillcrest Center's CMS Rating?
CMS assigns HILLCREST CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Pennsylvania, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Hillcrest Center Staffed?
CMS rates HILLCREST CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 34%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Hillcrest Center?
State health inspectors documented 32 deficiencies at HILLCREST CENTER during 2023 to 2025. These included: 1 that caused actual resident harm and 31 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Hillcrest Center?
HILLCREST 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 GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 180 certified beds and approximately 164 residents (about 91% occupancy), it is a mid-sized facility located in WYNCOTE, Pennsylvania.
How Does Hillcrest Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, HILLCREST CENTER's overall rating (4 stars) is above the state average of 3.0, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Hillcrest 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 Hillcrest Center Safe?
Based on CMS inspection data, HILLCREST 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 4-star overall rating and ranks #1 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 Hillcrest Center Stick Around?
HILLCREST CENTER has a staff turnover rate of 34%, which is about average for Pennsylvania nursing homes (state average: 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 Hillcrest Center Ever Fined?
HILLCREST CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Hillcrest Center on Any Federal Watch List?
HILLCREST 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.