Pennsylvania Department of Health
BEACON RIDGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 74 surveys for this facility. Please select a date to view the survey results.

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BEACON RIDGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey, completed on May 22, 2025, it was determined that Beacon Ridge was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for five of 38 residents reviewed (Resident 1, 13, 25, 29, 75).

Findings include:

The facility's policy regarding homelike environment, dated January 2, 2025, indicated that the facility staff and management were to the extent possible maximize the characteristics of the facility that reflect a personalized homelike setting including a clean, sanitary, and orderly environment.

Observations of Resident 1's room on May 22, 2025, at 9:10 a.m. revealed that there was a large area of dried chipping paint, approximately 24 inches by 10 inches above the heating/cooling unit.

Interview with the Maintenance Director on May 22, 2025, at 9:40 a.m. revealed that he was not aware of the chipping paint and indicated that with all the rain lately that moisture must be coming in the walls.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated December 2, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, was independent for care needs, and had diagnoses that included anxiety and manic depression.

An admission MDS assessment for Resident 29, dated December 18, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required supervision to moderate assistance for care needs, and had diagnoses that included orthostatic hypotension (low blood pressure with changes in body position) and diabetes mellitus.

Observations of Resident 13 and 29's room 217 on May 19, 2025, at 11:20 a.m. revealed that there was an area of broken dry wall, approximately 18 inches by 18 inches, near the packaged terminal air conditioner (PTAC - a self-contained through-the-wall heating and air conditioning unit). There was also a resident blanket rolled up sitting on the window sill and the wall was starting to bubble under the paint on either side of the window. In the corner of the window was a three-inch line of a black/grey, removable substance. The wall trim below the wall was pulling away from the wall and in some areas lying on the floor. The window sill was loose and breaking apart in the corner. Interview with Residents 13 and 29 at the time of the observations revealed that they put a blanket on the windowsill to block out the cold draft. A little bit ago some of the pieces of the wall fell on the floor, and maintenance staff cleaned it up, and said they would be back to clean it up. However they have not returned to fix anything.

Observations of Resident 13 and 29's room on May 22, 2025, at 9:52 a.m. revealed the PTAC and window conditions were the same and the blanket was now wet. Interview with Resident 29 at the time of the observations indicated no staff have come in to fix the area.

Interview with Maintenance Director on May 22, 2025, at 11:23 a.m. revealed that maintenance concerns from nursing are communicated with paper slips that are picked up daily. He confirmed that the areas of dry wall were in need of repair, water was coming in through the window causing water damage to the windowsill making it loose and breaking apart, the paint and wall trim had water damage, there was a black, removable substance on the corner of the window, and that the areas were not homelike. There was no work order that he was aware of in the system, and he was not aware this room needed such repairs. He also indicated that the flashing above the window may be a concern, which allows water to come in behind the stucco.

Observations of Resident 25's room on May 22, 2025, at 9:21 a.m. revealed that there was an area of broken out drywall, approximately seven inches by seven inches on the wall below the window next to the floor.

Observations of Resident 75's room on May 22, 2025, at 9:30 a.m. revealed that there was an area of dried visibly chipping paint, approximately 12 inches by 10 inches above the heating/cooling unit.

Interview with the Maintenance Director on May 22, 2025, at 9:52 a.m. revealed that he was not aware of the chipping paint in rooms 1 and 25, or the broken drywall in Resident 75's room. He indicated that it was unacceptable and that his staff would be correcting the concerns.

28 Pa. Code 207.2(a) Administrator's Responsibility.

Plan of Correction - To be completed: 07/01/2025

Preparation and evaluations of the following plans of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plans for correction are prepared and/or executed solely because it is required by the provision of Federal and State law.

The facility is unable to retroactively correct the observations on 05/19/2025 and 05/22/2025. There were no ill effects noted. The areas of concern have been repaired.

The Maintenance department will be educated on the requirement for a safe, clean, comfortable and homelike environment.

Staff has been educated to report any areas of concern. The areas will be reviewed at start up/stand up meeting for completion.

The Maintenance Director and/or designee will complete an initial audit on areas that require maintenance and repairs. Then random audits will be completed weekly for 4 weeks and then monthly for 3 months.

Audit results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observation on 05/19/2025 of Resident 10 and 05/21/2025 of Resident 4 regarding their foley bag placement.

The catheter tubing was properly secured on Resident 10 following the observation on 05/19/2025. The catheter tubing was properly secured on Resident 4 following the observation on 05/21/2025

The Director of Nursing and/or designee will educate the Nursing Staff on having proper securement of the catheter tubing.

An audit of residents with catheters was completed to identify that the catheters tubing was properly secured. No other residents were identified.

The Director of Nursing and/or designee will complete audits to verify that the catheter tubing is properly secured weekly for 4 weeks and then monthly for 3 months.

The facility is unable to retroactively correct the observation on 05/21/2025 of Resident 7 regarding the catheter change scheduled for 05/05/2025.

The order was reviewed with the Primary Care Physician and the order was revised to be changed as needed for blockage, dislodgment or if damaged to the integrity of the catheter as needed to reflect the current standard of practice.

The Director of Nursing and/or designee will educate the Licensed Nursing Staff on changing the catheter per physician order.

An audit of residents with catheters was completed to identify that the catheters were changed per physician order.

The Director of Nursing and/or designee will complete audits to verify that the catheters were changed per physician order weekly for 4 weeks and then monthly for 3 months.

Audit results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect a resident's specific care needs for three of 38 residents reviewed (Residents 35, 47, 50).

Findings include:

A facility policy regarding comprehensive person-centered care plans, dated January 2, 2025, indicated that comprehensive, person-centered care plans are developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change.

A quarterly MDS assessment for Resident 35, dated February 26, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and had a diagnosis of hypertension (high blood pressure). A care plan for Resident 35, dated September 16, 2024, indicated that the resident was receiving a diuretic (a medication used to treat fluid retention and hypertension) related to edema (fluid retention in body tissues) and hypertension. Review of Resident 35's clinical record, including review of the resident's Medication Administration Record (MAR), revealed no documented evidence that the resident was receiving a diuretic.

Interview with the Nursing Home Administrator on May 21, 2025, at 2:02 p.m. confirmed that Resident 35's care plan should have been revised to reflect that he was not receiving a diuretic.

A quarterly MDS assessment for Resident 47, dated March 1, 2025, indicated that the resident was cognitively intact, was understood, usually understands, was independent with care needs, and had a diagnoses of dementia, anxiety, depression, and bipolar disease (shifts in mood, energy, and activity levels, encompassing both periods of manic and depression). A care plan for Resident 47, dated March 3, 2023, indicated that the resident was an elopement risk and a wanderer with impaired safety awareness. The care plan included an intervention to have a code alert bracelet at all times numbered 9000-0434J with an expiration date of April 21, 2024.

Physician orders for Resident 47, dated March 22, 2025, included an order to have code alert bracelet on at all times numbered 9000-0434M with expiration date October 25, 2025, and checked for placement every shift.

Observations of Resident 47 on May 21, 2025, at 11:11 a.m. revealed that the resident was lying in bed. Licensed Practical Nurse 1 checked the alert bracelet and it was labeled 9000-0434M with an expiration date of October 25, 2025.

Interview with the Nursing Home Administrator on May 21, 2025, at 2:01 p.m. confirmed that Resident 47's care plan should have been revised to reflect the correct code alert bracelet information.

An annual MDS assessment for Resident 50, dated May 7, 2025, indicated that the resident was cognitively impaired, was usually able to make herself understood and was usually able to understand others, and required assistance with care needs. A care plan for Resident 50, dated February 17, 2025, indicated that the resident had a urinary tract infection with an intervention that included to give antibiotic therapy as ordered. Review of Resident 50's clinical record, including review of the resident's Medication Administration Record (MAR), revealed no documented evidence that the resident had a urinary tract infection and no documented evidence that she was receiving an antibiotic.

Interview with the Nursing Home Administrator on May 22, 2025, at 10:11 a.m. indicated that she believed Resident 50's care plan should have stayed in effect related to her MDS.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observation regarding Resident 35, 47 and 50 and their care plan revisions.

Upon identification the care plan's were revised to reflect the resident's specific care needs.

The RNAC (Registered Nursing Assessment Coordinator) and/or designee will re educate the LPNAC (Licensed Practical Nurse Assessment Coordinator) and Licensed Nursing staff on having the care plans reflect the resident's specific care needs.

The RNAC and/or designee will complete audits to verify that the care plans reflect the resident's specific care needs and diagnosis weekly for 4 weeks and then monthly for 3 months.

Audit results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a care plan was created to reflect the resident's specific care needs for one of 38 residents reviewed (Resident 7).

Finding include:

A facility policy, dated January 2, 2025, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It will aid in preventing or reducing decline in the resident's functional status and/or functional levels and assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated, May 5, 2025, revealed that the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of Parkinson's disease.

Clinical record review for Resident 7 revealed that there was no documented evidence that a care plan was created to address specific care needs related to Parkinson's disease.

Interview with the Nursing Home Administrator on May 21, 2025, at 10:48 a.m. confirmed that Resident 7 did not have a care plan developed to address her specific care needs related to Parkinson's disease, and it should have been.

28 Pa. Code 201.24(e)(4) Admission Policy.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observation regarding Resident 7 and their diagnosis of Parkinson's disease being care planned.
Upon identification the care plan was revised to include the diagnosis of Parkinson's disease.

The RNAC (Registered Nursing Assessment Coordinator) and/or designee will re educate the LPNAC (Licensed Practical Nurse Assessment Coordinator) on having the care plans reflect the resident's specific care needs and diagnosis.

The RNAC and/or designee will complete audits to verify that the care plans reflect the resident's specific care needs and diagnosis weekly for 4 weeks and then monthly for 3 months.

Audit results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to safely transfer one of 38 residents reviewed (Resident 62) who required assistance from staff for transfers.

Findings include:

An admission minimum data set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 4, 2025, indicated that he was alert and oriented, required moderate assistance for daily care needs, and assist of one for transfers with wheeled walker and gait belt.

Observations of Resident 62 on May 22, 2025, at 8:24 a.m. revealed that Nurse Aide 2 transferred the resident from a seated position to his wheelchair by using the back of his pants while there was a gait belt on the back of his wheelchair.

Interview with Nurse Aide 2 on May 22, 2025, at 8:26 a.m. revealed that she was aware of Resident 62's transfer status and that she did not use a gait belt for the transfer instead she used the back of his pants for the transfer.

Interview with Nursing Home Administrator on May 22, 2025, at 2:08 p.m. confirmed that Resident 62 should have been transferred with the use of a gait belt and he was not.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observation on 05/22/2025 of Resident 62 being transferred without the use of a gait belt.

The Director of Nursing and/or designee will educate nursing staff regarding the policy on utilizing identified/ care planned assistance devices for transfer to prevent accidents.

The Director of Nursing and/or designee will complete random audits on the use of assistance devices for transfer weekly for 4 weeks and then monthly for 3 months.

Audit results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 38 residents reviewed (Resident 35).

Findings include:

A facility policy regarding medication administration, dated January 2, 2025, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 26, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and was taking an opioid medication (medications with the potential to be abused used to treat pain).

Physician's orders for Resident 35, dated January 30, 2025, included an order for the resident to receive 5-325 milligrams (mg) of Hydrocodone-Acetaminophen (a narcotic pain medication) every six hours as needed for pain.

Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 35, dated February, March, April and May 2025, revealed that a 5-325 mg tablet of Hydrocodone-Acetaminophen was signed out on February 22 at 10:00 p.m.; February 23 at 5:30 a.m. and 9:00 p.m.; March 8 at 9:00 p.m.; March 9 at 8:30 a.m.; March 10 at 3:15 a.m.; March 20 at 9:06 p.m.; March 22 at 9:00 p.m.; March 23 at 6:00 a.m.; March 23 at 9:00 p.m.; March 24 at 6:00 a.m.; March 30 at 8:47 p.m.; April 9 at 6:00 a.m.; April 10 at 9:00 p.m.; April 11 at 6:00 a.m.; April 11 at 9:51 p.m.; April 22 at 6:00 a.m.; May 10 at 9:34 p.m.; and May 11 at 9:26 p.m. However, there was no documented evidence in Resident 35's clinical record, including the MAR, that the signed-out doses of Hydrocodone-Acetaminophen were administered to the resident on the above-mentioned dates and times.

Interview with the Director of Nursing on May 21, 2025, at 1:38 p.m. confirmed that there was no documented evidence in Resident 35's clinical record to indicate that the signed-out doses of Hydrocodone-Acetaminophen were administered to the resident on the above-mentioned dates and times.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observation for Resident 35, as it is a past event. There were no ill effects noted.

An initial audit of residents currently receiving Hydrocodone was completed to assure that the medication is documented on the Medication Administration Record (MAR) and on the controlled medication count sheet.

The Director of Nursing and/or designee will re educate the Licensed Nursing Staff on medication administration documentation.

The Director of Nursing and/or designee will complete audits to verify that the administered controlled substances had the proper administration documentation weekly for 4 weeks and then monthly for 4 months.

Audit results will be reviewed at the Quality Assurance and Performance Improvement Committee.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;

Observations:

Based on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent.

Findings include:

A facility policy regarding medication administration, dated January 2, 2025, indicated that medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Each nurses' station has a current Physician's Desk Reference (PDR) and/or other medication reference available.

Observations during medication administration on May 21, 2025, revealed that three medication administration errors were made during 29 opportunities for error, resulting in a medication administration error rate of 10.34 percent.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated May 6, 2025, indicated that the resident was cognitively impaired, required assistance from staff for care needs, and had diagnoses that included hypertension (high blood pressure).

Physician's orders for Resident 32, dated March 30, 2023, included an order for the resident to receive 25 milligrams (mg) of Metoprolol Succinate ER (Extended-Release) tablet daily related to hypertension.

Observations of medication administration on May 21, 2025, at 8:16 a.m. revealed that Licensed Practical Nurse 1 crushed the extended-release tablet of Metoprolol Succinate prior to administering the medication to Resident 32.

Interview with Licensed Practical Nurse 1 on May 21, 2025, at 9:50 a.m. confirmed that she should not have crushed Resident 32's extended-release tablet of Metoprolol Succinate.

A quarterly MDS assessment for Resident 55, dated April 4, 2025, indicated that the resident was cognitively impaired, required assistance from staff for care needs, and had diagnoses that included obstructive uropathy (blockage of the urinary tract) and benign prostatic hyperplasia (enlarged prostate).

Physician's orders for Resident 55, dated December 5, 2023, included an order for the resident to be administered a 0.4 mg capsule of Tamsulosin HCL daily related to benign prostatic hyperplasia.

Observations of medication administration on May 21, 2025, at 7:48 a.m. revealed that Licensed Practical Nurse 5 removed the contents of the Tamsulosin HCL capsule, placed the contents in applesauce, and administered the medication to Resident 55. Manufacturer's instructions for Tamsulosin HCL indicated that the capsules should not be crushed, chewed or opened.

Interview with Licensed Practical Nurse 5 on May 21, 2025, at 9:44 a.m. confirmed that she removed the contents of the Tamsulosin HCL capsule prior to administering the medication to Resident 55 and that she was not aware that the medication should not be removed from the capsule.

An admission note for Resident 129, dated May 20, 2025, indicated that the resident had diagnoses that included heart disease and presence of right artificial hip joint. Physician's orders revealed that the resident was admitted to the facility on May 20, 2025, with an order for aspirin 325 milligrams (mg) give one tablet daily for blood clot prevention related to right artificial hip joint.

Observations of medication administration on May 21, 2025, at 8:24 a.m. revealed that Licensed Practical Nurse 6 administered aspirin 81 mg instead of the ordered dose of 325 mg.

Interview with Licensed Practical Nurse 6 on May 21, 2025, at 11:25 a.m. confirmed that she administered aspirin 81 mg instead of the physician ordered dose of 325 mg.

Interview with the Nursing Home Administrator on May 21, 2025, at 3:35 p.m. confirmed that Resident 32's metoprolol succinate extended-release table should not have been crushed, that the contents of the Tamsulosin HCL capsule should not have been removed prior to administering the medication to Resident 55, and that Resident 129 should not have received aspirin 81 mg, but rather the correct physician-ordered dose of aspirin 325 mg.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observation for Resident 55, Resident 32 and Resident 129 from 05/21/2025 as it is a past event. There were no ill effects noted.

The Director of Nursing and/or designee will re educate the Licensed Nursing Staff on medication administration in accordance with prescriber orders.

The Director of Nursing and/or designee will complete audits to verify that the medications are administered in accordance with the prescriber orders weekly for 4 weeks and then monthly for 4 months.

Audit results will be reviewed at the Quality Assurance and Performance Improvement Committee.

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must 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.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending June 6, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 22, 2025, identified repeated deficiencies regarding safety and accident hazards, failure to provide proper catheter care, and failure to ensure the accountability of controlled substances.

The facility's plan of correction for a deficiency regarding safety and accident hazards, cited during the survey ending June 6, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding safety and accident hazards.

The facility's plan of correction for a deficiency regarding a failure to provide proper catheter care, cited during the survey ending June 6, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F690, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding catheter care.

The facility's plan of corrections for deficiencies regarding accountability of controlled substances, cited during the survey ending June 6, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accountability of controlled substances.

Refer to F689, F690 and F755.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observations related to Quality Assurance and Performance Improvement. The facility has developed plans of correction for the observations of this survey related to F689, F690, F755.

The Quality Assurance Performance Improvement (QAPI) committee uses a root cause approach in addressing new deficiencies as well as repeat deficiencies. Plans for auditing recurring deficiencies have been established to monitor compliance for F689, F690, F755.

The Administrator and/or Quality Assurance Performance Improvement Committee member will complete random audits to monitor the effectiveness of the plans of corrections for the recurring deficiencies weekly for 4 weeks then monthly for 4 months.

The audit results will be reviewed at the Quality Assurance Performance Improvement Committee meetings.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on review of Pennsylvania state law, as well as staff interviews, it was determined that the facility failed to ensure that the multi-disciplinary infection control committee meetings contained all the required members.

Findings include:

The Act 52 Infection Control Plan, dated January 25, 2024, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multi-disciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that could include the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, members from the infection control team, and a community member that may not be an agent, employee or contractor of the facility.

As of May 22, 2025, the facility was unable to provide documented evidence that the facility's multi-disciplinary infection control meetings contained all of the required members.

Interview with the Nursing Home Administrator on May 22, 2025, at 10:08 a.m. confirmed that laboratory personnel were not attending the infection control meetings and indicated that she believed laboratory personnel were not required to attend the infection control meetings. Interview with the consultant at that time confirmed that a laboratory personnel should be present at the meetings at least quarterly as per the Act 52 Infection Control Plan.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observation for the laboratory personnel for the multi-disciplinary infection control committee meetings. There were no ill effects noted.

The Infection Control Committee members: Administrator, Director of Nursing, Assistant Director of Nursing and Infection Control Nurse and/or designee were reeducated on the need for a laboratory personnel to be present at least quarterly.

The Administrator and/or designee will complete audits to verify that the required members are attending the Infection Control Committees at least quarterly; audits to be completed quarterly x2.

The audit results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

§ 205.28(c)(1)-(4) LICENSURE Nurses' station.:

(c) The nurses ' station shall have facilities for:
(1) A nurses ' call system.
(2) Charting and supplies.
(3) Medication storage and preparation, which may be within the clean workroom, if a self-contained cabinet is provided. The medication storage cabinet shall be locked. Mechanical ventilation shall be provided in this workroom. If a medication cart is used, provisions shall be made to lock the cart or to place the cart when not in use in a safe area that can be locked. The cart may not be stored in the corridor.
(4) A double-locked narcotic compartment within the medication area.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that medication carts were not stored in the corridors when not in use.

Findings include:

Observations on the Bayside Unit on May 19, 2025, at 11:45 a.m., and 2:15 p.m.; May 20, 2025, at 11:18 a.m., 1:40 p.m. and 3:00 p.m.; May 21, 2025, at 10:55 a.m. and at 12:32 p.m.; and May 22, 2025, at 10:45 a.m., 1:02 p.m. and 2:31 p.m., revealed two medication carts that were not in use and were stored in the corridor, one on each side of the 300 hall lounge entrance.

Interview with Licensed Practical Nurse 6 on May 22, 2025, at 2:31 p.m. confirmed that the medication carts were stored in the corridor on the Bayside Unit when not in use.

Interview with the Nursing Home Administrator on May 22, 2025, at 2:48 p.m. confirmed that the medication carts were stored in the corridor when not in use, and they should not have been.

Plan of Correction - To be completed: 07/01/2025

The facility is unable to retroactively correct the observations of the medication carts being stored in the corridor.

The Director of Nursing and/or designee will re educate the Licensed Nursing Staff that medication carts cannot be stored in the corridor.

The Director of Nursing and/or designee will complete audits to verify that the medication carts are not stored in the corridor.

The audit results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

Preparation and evaluations of the following plans of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plans for correction are prepared and/or executed solely because it is required by the provision of Federal and State law.

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