Pennsylvania Department of Health
INGLIS HOUSE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

INGLIS HOUSE
Inspection Results For:

There are 228 surveys for this facility. Please select a date to view the survey results.

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INGLIS HOUSE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to five complaints, and two facility reported incidents, completed June 16, 2026, it was determined that Inglis House 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 related to the health portion of the survey process.

Plan of Correction:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

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.

�483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:
Based on review of facility policy, review of facility documentation, observations, and interviews with staff and residents it was determined that the facility failed to provide timely assistance with activities of daily living care for dependent residents for 3 of 10 residents reviewed (Resident R2, R9 and R6).

Findings Include:

Review of facility grievance records from January 2026 through June 2026 revealed ongoing concerns regarding staff responsiveness and timeliness of care. The monthly grievance logs documented repeated complaints involving delayed incontinence care, residents not awakened for care services, and delays in responding to resident requests.

Review of Resident R2's Minimum Data Set (MDS- federally mandated resident assessment and care screening) dated March 22, 2026, revealed the resident is cognitively intact, able to communicate his/her needs and preferences, and has a suprapubic catheter (urinary drainage tube that is surgically inserted through the abdominal wall directly into the bladder to continuously drain urine).

Further review of Resident R2's MDS revealed the resident has diagnoses of neurogenic bowel (loss of normal bail function due to neurological condition affecting the nerves that control the bail elimination), paraplegia (paralysis affecting the lower half of the body including both legs), and multiple sclerosis (a chronic progressive disease of the central nervous system that can impair movement sensation and bodily functions).

Interview on June 16, 2026, at 8:20 a.m., with Resident R2 the resident reported his/her urinary catheter was leaking, and that nursing staff was informed. Resident R2 reported waiting for a nurse to address the issue.

Interview June 16, 2026, at 8:20 a.m., with the Unit Manager, Employee E14, confirmed awareness of the leaking catheter but, was administering medications and would address the concern later.

Observation on June 16, 2026, at 9:51 a.m. revealed Resident R2 received care, approximately 1.5-hours after assistance was requested.

Observations on June 16, 2026, at 8:30 a.m. revealed Resident R9 and R6 were eating breakfast.

Interview June 16, 2026, at 8:30 a.m. with Resident R9 revealed his/her brief was wet, and incontinence care had not been provided since the previous night. Subsequent interview with Resident R6, the resident also reported not receiving incontinence care since the night before. Resident R6 revealed this is a frequent occurrence, and he/she is often left in a soiled or wet brief for extended period of time.

Interview on June 16, 2026, at 8:45 a.m. with Registered Nurse, Employee E13, confirmed that Resident R9 and R6 were eating breakfast and had not yet received morning incontinence care or brief changes.

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

Plan of Correction - To be completed: 08/11/2026

1.Resident R2 catheter was changed by the RN supervisor from 1 North before lunch time. R9 and R6 received their incontinent care immediately after breakfast before 12pm on 6/16/2026 during the visit.
2. Facility will do a sweep of interviewable residents to determine if the facility is meeting their needs regarding incontinent care. all Non interviewable residents will be indicated and we will receive incontinent care if needed during scheduled rounds.
3. Staff will be educated on importance of incontinent care including Skin health and hygiene, impacts on resident's skin related complications, and prevention of skin breakdown.
4. Weekly incontinent care audits will be completed in all shifts and check non-verbal residents. Audits will be completed weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meetings.

483.24 (a) (3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):

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.

�483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.

Observations:
Based on review of personnel files and staff interviews it was determined that the facility failed to ensure licensed, direct-care staff maintained current certification in Cardiopulmonary Resuscitation (CPR) for one of four personnel files reviewed (Employee E15).

Findings Include:

Review of personnel file for Respiratory Therapist, Employee E15, revealed the employee had an expired CPR certification (Cardiopulmonary Resuscitation -lifesaving procedure that maintains blood flow and oxygen to the brain and heart when the heart or breathing stops).

Interview on June 16, 2026, with Respiratory Therapist, Employee E15, confirmed CPR training was not renewed.

Interview on June 16, 2026, with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed Respiratory Therapist, Employee E15, had an expired CPR certification.

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

Plan of Correction - To be completed: 08/11/2026

1.Employee E15 received her C P R training on 6/16/2026.
2.Facility will gather a list of all CPR certified licensed staff in the facility and will ensure that they have an adequate number of licensed staff certified in CPR available 24/7 in the event of emergencies
3.Respiratory therapist and Licensed Practical nurses will be educated on the importance of maintaining their k C P R certification
4.The staff Educator or designee will keep track of staff C P R statuses. A monthly report will be reviewed by the Director of Nursing or designee for staff C P R status x 4 months and results reviewed at QAPI Meeting

483.25 REQUIREMENT Quality of Care:

� 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:
Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to administer medications in accordance with physician orders for one of ten residents reviewed (Resident R4).

Findings Include:

Review of facility policy titled "General Medication Procedures", revised September 3, 2025, revealed the purpose of the policy is to ensure residents receive medications in a timely manner, maintain continuity of prescribed therapeutic regimens, ensure prompt administration of initial medication doses, and provide medications in accordance with physician orders. The policy establishes that nursing staff are responsible for ensuring medications are available, accurately prepared, administered timely, and monitored to ensure residents receive prescribed medications without unnecessary delay or interruption.

Observation on June 16, 2026, at 10:21a.m. revealed restorative aid, Employee E18, responded to Resident R4's activated call bell. When the call-bell was answered, Resident R4 reported he/she was still waiting to receive morning medications and requested that restorative aide, Employee E18, notify the nurse to administer his/her medications.

Review of Resident R4's clinical record revealed a physician order for baclofen (muscle relaxant) 20 milligram one tablet three times daily scheduled for administration at 8:00 AM, 2:00 PM and 10:00 PM.

Further review of Resident R4's clinical record revealed a physician order for gabapentin 800 milligram two tablets three times daily for pain scheduled for administration at 8:00 AM, 2:00 PM and 10:00 PM.

Interview June 16, 2026, at 10:55 AM, with Licensed Nurse, Employee E19, confirmed Resident R4 had not yet received Baclofen and Gabapentin that were scheduled for administration at 8:00 a.m.

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

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

Plan of Correction - To be completed: 08/11/2026

1.Resident R5 (not R4 in 2567) received morning medication on 6/16/26. Medication administration times will be altered to ensure timeliness of medication administration.
2.Facility will take a look at all current medication times. All residents who are scheduled for early med administration will be reviewed by physicians and nurse leadership.
3. Nurses will be educated on how to identify the times and schedules of medications for their med pass.
4. The Medication Audit Administration report for late medications will be reviewed by Director of nursing or designee x 14 days, then weekly x 4 weeks, monthly x 2 months and results reviewed at the QAPI committee meeting

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

�483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

�483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

�483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

�483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:
Based on review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of ten residents reviewed (Resident R1).

Findings Include:

Review of Resident R1's clinical record revealed the resident was admitted to the facility on September 13, 2023, has a BIMS (brief interview for mental status) score of 15 (indicating intact cognitive function), and requires set-up assistance for eating.

Review of Resident R1's clinical record revealed the resident has diagnoses of thyroid disorders (condition in which the thyroid has not produced hormones at proper levels affecting metabolism energy overall body function), paraplegia (often caused by spinal cord injury or disease resulting in the loss of movement and sensation), attention deficithyperactivity disorder (ADHD- characterized by persistent patterns of inattention, hyperactivity, and impulsivity), and anxiety (fear or nervousness).

Review of Resident R1's comprehensive care plan revealed the resident's diagnosis of hyperthyroidism and ADHD has the potential to affect the resident's nutritional status and weight.

Further review of Resident R1's comprehensive care plan dated September 13, 2023, revealed the resident is at risk for nutritional problems with interventions in place to monitor weight status, adherence to prescribed diet, providing nutritional supplements as ordered, educating the resident regarding malnutrition risks, and having the Registered Dietitian evaluate the resident and make dietary recommendations as needed.

Review of Resident R1's clinical record revealed the following weight history:

03/18/2026 180.2-pounds
04/02/2026 175.2-pounds
04/22/2026 174.2-pounds
05/09/2026 172.2-pounds
05/21/2026 168.2-pounds
06/02/2026 166.2-pounds

Review of resident R1's weight records revealed the resident's weight declined from 180.2 pounds on March 18, 2026, to 166.2 pounds on June 2, 2026, representing a 14-pound (7.8%) loss in approximately 76 days, meeting CMS (Centers for Medicare and Medicaid Services) criteria for significant weight loss within a 90-day period.

Review of Resident R1's clinical record revealed a nutritional assessment completed on April 20, 2026. Resident R1 was assessed with a weight of 176.8-pounds and no significant weight changes were documented.

Review of Resident R1's clinical record revealed the resident's weight continued to trend down to 166.2-pounds, sustaining another 10.6-pound significant weight loss since the last nutrition assessment completed April 20, 2026.

Further review of resident R1's clinical record revealed no documented evidence the significant weight loss was reviewed or addressed.

Interview on June 16, 2026, at 1:30 p.m. with Registered Dietitian, Employee E5, confirmed Resident R1 sustained a significant weight loss. Further interview with Registered Dietitian, Employee E5, revealed re-weights were ordered but not yet completed.

28 Pa. Code 211.10 (d) Resident care policies.

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

Plan of Correction - To be completed: 08/11/2026

1.Resident R1 re-weight was completed on 6/17/2026. It was determined no weight loss by the Registered Dietitian.
2.Facility will review all residents who have had significant weight loss in the last 6 months. To ensure all matters were addressed appropriately
3.Staff will be educated on the importance of obtaining re-weights.
4.In The Morning Clinical Meeting will review the residents who need the weight and re-weight daily. Reweight will be reviewed at the stand down meeting for follow up as needed. Dietician will document any weight changes and interventions or lack thereof for residents being weighed weekly at least once per month. A weight report will be reviewed by the Registered Dietitian weekly x 4 weeks, then monthly x 2 months to ensure notes are in the system to correspond to significant weight changes. All results reviewed at the QAPI Committee meeting.

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