Pennsylvania Department of Health
HIGHLANDS AT WYOMISSING, THE
Patient Care Inspection Results

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HIGHLANDS AT WYOMISSING, THE
Inspection Results For:

There are  61 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
HIGHLANDS AT WYOMISSING, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed on May 21, 2025, it was determined that The Highlands at Wyomissing 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 as they relate to the Health portion of the survey.



 Plan of Correction:


483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:
Based on observation, facility policy review, and staff and resident interview, it was determined that the facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units which placed residents at risk for burn injuries. (Heather Court, units 100, 200, and 300) This failure resulted in an Immediate Jeopardy situation.

Findings include:

Review of documentation by the American Burn Association's Burn Prevention Committee entitled, "Scald Injury Prevention," revealed that a scald injury occurred when a hot liquid damaged one or more layers of skin and hot beverages were a frequent source of scald burns. Older adults were the most frequent victims of scald injuries due to thin skin, reduced mobility, and reduced ability to feel heat. Hot liquid at a temperature of 155 degrees Farenheit (F) could result in a scald injury in one second.

Review of the facility policy entitled, "Service Temperatures," last reviewed July 2024, revealed that staff were to ensure that temperatures were within critical limits and that coffee was to be a minimum of 150 degrees F and a maximum 180 degrees F. The policy indicated that hot beverages could be served at temperatures greater than 155 degrees F, contrary to the safety parameters outlined by the American Burn Prevention Committee.

Observation during a test tray audit conducted on May 20, 2025, at 11:53 a.m., at the time the last resident meal tray was served, it was determined that the coffee provided on the tray was 179 degrees F. In an interview during the tray audit, Dietary Manager (DM) 1 confirmed the temperature of the coffee was 179 degrees F and that temperature was excessively hot for coffee at the point of service.

In an interview on May 20, 2025, at 12:04 p.m., Dietary Aide (DA) 1 stated that she did not test the temperature of the coffee before the start of service or before the trays left the kitchen. She also stated that she did not typically test the temperature of the coffee before service to residents. There was a lack of evidence to support that any staff were testing the temperature of the coffee before service to residents.

In an interview on May 20, 2025, at 1:20 p.m., DM 1 stated that Residents 1, 3, 4, 8, 14, and 23 typically ordered and drank coffee from the dietary department on a regular basis.

In an interview on May 20, 2025, at 1:30 p.m., the Administrator stated that the facility did not have a procedure in place to assess a resident's ability to safely manage hot beverages.

In interviews on May 20, 2025, at 4:10 p.m., and 4:22 p.m., Residents 4 and 8 stated that the coffee was often served hot and they could not drink it when served.

On May 20, 2025, at 3:36 p.m., the Administrator was notified that the failure to ensure hot beverages were served at a safe temperature constituted an Immediate Jeopardy situation at F 804 K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.

The facility provided an acceptable action plan for removal of the Immediate Jeopardy on May 20, 2025, at 7:19 p.m. The facility's action plan contained the following:

1. The temperature of hot beverages would be recorded by a dietary aide on a log at the start of every meal service. If the temperature of the beverage exceeded 150 degrees F, the liquid would be poured into a serving vessel to allow time to cool to the appropriate temperature and the temperature would be retested to ensure it was within range before service.

2. Dining services revised their policy to reflect a safe serving temperature of hot beverages to be between 130 degrees F and 150 degrees F.

3. All scheduled dietary staff who were onsite were educated on the safe service temperature of hot beverages and the procedure to monitor temperatures of hot beverages. One hundred percent (%) of all staff would be educated by May 23, 2025.

4. The Dietary department would contact the manufacturer of the coffee machine on May 21, 2025, to determine if the setting of the machine could be adjusted to brew at a lower temperature. The settings would be adjusted if able to do so.

5. The Dietary Supervisor would conduct weekly audits of the temperature logs to ensure that temperatures were properly obtained and were within the safe range for service.

6. If it was determined that temperatures of hot beverages were not being obtained before meal service or that hot beverages were being served outside of the safe temperature range, an additional in-service would be held with dietary staff to ensure understanding.

The survey team validated that Immediate Jeopardy was removed on May 20, 2025, at 7:19 p.m., through observation, staff interview, review of staff training, and review of the facility policy and procedure following the facility's implementation of the action plan for removal of the Immediate Jeopardy.

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

28 Pa. Code 201.18(b)(1)(3) Management.










 Plan of Correction - To be completed: 06/04/2025

The temperature of hot beverages will be recorded by a dietary aide on a log at the start of every meal service. If the temperature of the beverage exceeded 150 degrees F, the liquid will be poured into a serving vessel to allow time to cool to the appropriate temperature and the temperature would be retested to ensure it is within range before service.

Dining services revised their policy to reflect a safe serving temperature of hot beverages to be between 130 degrees F and 150 degrees F.

All scheduled dietary staff who are onsite will be educated on the safe service temperature of hot beverages and the procedure to monitor temperatures of hot beverages. One hundred percent (%) of all staff would be educated by May 23, 2025.

The Dietary department will contact the manufacturer of the coffee machine on May 21, 2025, to determine if the setting of the machine can be adjusted to brew at a lower temperature. The settings will be adjusted if able to do so.

The Dietary Supervisor will conduct weekly audits of the temperature logs to ensure that temperatures were properly obtained and were within the safe range for service.

If it is determined that the temperatures of hot beverages are not obtained before meal service or that hot beverages were served outside of the safe temperature range, an additional in-service would be held with dietary staff to ensure understanding.

A mandatory in-service training will be hosted on June 4, 2025, with Sophie Campbell of PADONA to review regulation and importance of compliance.
Copy of PowerPoint presented during mandatory in-service training to be available following training to provide to any relevant staff that are unable to attend training.

Proof of education and attendance to be available following June 4 training.

The coffee that was tested for temperature at the time of survey was not served to a resident.

Manufacturer of coffee machine completed service call and temperature was adjusted.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments: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.
§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) within 14 days after the facility completed the resident assessment for one of three sampled residents who were discharged from the facility. (Resident 45)

Findings include:

Clinical record review revealed that Resident 45's discharge MDS assessment was completed on December 20, 2024, but had not been exported as of May 20, 2025.

In an interview on May 21, 2025, at 11:00 a.m., Registered Nurse 1 confirmed that the MDS assessment had not been exported.





 Plan of Correction - To be completed: 06/13/2025

Education was provided on regulation and importance of timely MDS submissions provided to MDS Coordinator on 5/21/2025, following exit. Education was re-provided on 6/10/2025, per Field Office recommendation, to re-iterate importance of regulation and timely submission. Proof of education available for both 5/21/2025 following exit and 6/10/2025 for follow up education.

Upon return, DON reviewed and verified education provided to MDS coordinator and understanding of education by MDS coordinator on 5/27/25. DON present for re-education on 6/10/2025.


MDS Coordinator worked with IDT to discover dashboard within Point Click Care that shows all completed MDS assessments and added dashboard to main screen to ensure that completed assessments are submitted timely. MDS Coordinator will self-audit weekly for 90 days utilizing dashboard to ensure submission.

An audit of MDS assessments will also be completed monthly for 90 days during the Team Meeting with Director of Rehab and Finance Team. Team will review MDS assessments to ensure accuracy and correct submission monthly for 90 days and sign documentation to ensure completion of audit.

Initial Team audit will be completed on Thursday, June 12, 2025.
Self-audit and team audit of MDS submissions will be ongoing for 90 days.
MDS identified in citation was corrected prior to exit of surveyors.

The facility will be in compliance on June 13, 2025

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for two of three sampled residents who were transferred to the hospital. (Residents 7, 16)

Findings include:

Clinical record review revealed that Resident 7 was transferred to the hospital on March 22, 2025, after a change in condition. There was no documentation to support that the resident and the resident's responsible party or legal representative were provided with written information regarding the transfer to the hospital.

Clinical record review revealed that Resident 16 was transferred to the hospital on December 23, 2024, after a change in condition. There was no documentation to support that the resident and the resident's responsible party or legal representative were provided with written information regarding the transfer to the hospital.

In an interview on May 21, 2025, at 12:20 p.m., the Administrator confirmed that there was no evidence that the residents and residents' representatives were given written notices regarding the identified transfers.

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







 Plan of Correction - To be completed: 05/21/2025

Education was provided with Social Services Coordinator on 5/21/2025 on regulation and importance of issuing Transfer Notice form upon all discharges, including bed holds.
Signed education available as of 5/21/2025.

An audit of Transfer Notices will be conducted monthly for 90 days by the Administrator or designee during required Ombudsman reporting to ensure that Transfer Notices have been properly issued for all discharges.

Audits will be on-going for 90 days in accordance with the required monthly Ombudsman reporting.

Transfer notices will be issued to residents noted in deficiency and documented as being issued late.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 21 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from April 30, 2025, through May 20, 2025, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) from April 30, 2025, through May 20, 2025.



 Plan of Correction - To be completed: 06/04/2025

Director of Nursing or designee will review staffing schedules weekly with Skilled Nursing Scheduler to ensure adequate and compliant staffing.

The Director of Nursing or designee will randomly audit one week of staff schedules per month to ensure compliance with staffing requirements based on resident census.


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