Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

There are  125 surveys for this facility. Please select a date to view the survey results.

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on Abbreviated Survey was completed on April 4, 2024, it was determined that Eldercrest Health and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.

 Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident

Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Based on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of changes in a resident's blood glucose (BG) levels for one of two Residents (Resident R1).

Findings include:

Review of facility policy "Insulin Administration" last reviewed 12/15/23, indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Notify the physician if the resident has signs and symptoms of hypoglycemia (low blood sugar) that are not resolved by following the facility protocol for hypoglycemia management.

Review of facility policy "Management of Hypoglycemia" last reviewed 12/15/23, indicated for level one
BG less than 70 mg/dL. to notify the provider immediately.

Review of the clinical record indicated Resident R1 was admitted to the facility on 3/28/24, with the diagnoses that included diabetes(level one - high sugar in the blood), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat).

Review of a nurse progress noted dated 3/29/24, indicated the following:

At 12:30 a.m., BG was 52.
At 1:30 a.m., BG was 59.
At 2:30 a.m. BG was 60.
At 5:00 a.m. BG was checked two times for a reading of 56 and 61.

A review of the clinical record did not include documentation that the physcian was notified.

During an interview on 4/4/24, at 1:58 p.m., the Director of Nursing (DON) confirmed the above findings that the facility failed to notify the physician of changes in a resident's blood glucose levels for Resident R1.

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

28 Pa. Code 201.14(c)(e) Responsibility of licensee.

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

 Plan of Correction - To be completed: 04/23/2024

1. Resident R1 no longer resides in the facility.
2. Facility audit conducted on all patients with diabetes in order to ensure physician notification was completed for any patients outside of parameters.
3. All licensed nurses will be educated on Physician Notification for Changes in Condition including caring for those with diabetes.
4. Blood sugars will be audited for any changes in condition twice a week for four weeks then twice a month for one month to ensure that physician notification were made for any levels outside of parameters.
5. Findings will be submitted to QAPI Committee Meeting.

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