Pennsylvania Department of Health
IVY PARK POST ACUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

IVY PARK POST ACUTE
Inspection Results For:

There are 211 surveys for this facility. Please select a date to view the survey results.

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IVY PARK POST ACUTE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an onsite revisit survey completed on February 23, 2026, it was determined that Ivy Park Post Acute failed to correct the deficiencies cited during the survey of January 9, 2026, under the 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:

483.24(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 a review of facility documents and staff interviews, it was determined that the facility failed to make certain that all agency professional nursing staff were provided and attended the directed in-service (training required by the state agency that is presented by an outside vendor) outlined in the facility's plan of correction and as required. (all agency professional nursing staff)

Findings include:

A review of the facility's plan of correction for the survey ending 1/9/26, citation F678 J, indicated that the facility would contract with an outside vendor to provide a directed in-service to be attended by all professional nursing staff.

A review of the facility's attendance records for the directed in-service conducted on 1/31/26, revealed that that facility failed to make certain that agency professional nursing staff attended the directed in-service.

During an interview on 1/23/26, at 9:30 am the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the documents provided to verify agency professional nursing staff's education failed to provide documented evidence that the agency staff attended the directed in-service presented on 1/31/26, or a video recording of the presentation.

During an interview on 1/23/26, at 11:30 am Agency Licensed Practical Nurse (LPN) Employee E1 confirmed that she was provided education regarding Cardio Pulmonary Resuscitation (CPR), and that the facility failed to provide her with the direct in-service training.

During an interview on 1/23/26, at 11:40 am Agency LPN Employee E 2 confirmed that she received education via telephone by facility staff that reviewed CPR guidelines, and that the facility failed to provide her with the direct in-service training.

During an interview on 1/23/26, at 2:30 pm the Director of Nursing confirmed that facility failed to provide the direct in-service training to all agency professional nursing staff as required.

28 Pa Code: 201.14(a)(b) Responsibility of Licensee

Plan of Correction - To be completed: 03/16/2026

The facility provided licensed nurses cardiopulmonary education since the start of the initial IJ citation. There were no negative outcomes due to agency staff not receiving the in-service from the outside vendor.

Ivy Park Post Acute will audit all agency licensed staff who worked since the outside vendor provide the directed in-service on 1/31. The facility will reach out to those agency licensed nurses and educate them on the direct in-service, they will not be able to pick up any other shifts at the facility until this education is completed.

The directed in-service was posted on all agency platforms after our revisit on 1/24/26. Agency staff are not able to pick up a shift at the facility until the training is reviewed and signed off.

The facility will audit all agency staff members for the next 30 days to ensure ongoing compliance with education requirements.

The facility will be compliant with citation by 3/16/26.

483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt:

§483.75(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:

§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

§483.75(b)(1) Address all systems of care and management practices;

§483.75(b)(2) Include clinical care, quality of life, and resident choice;

§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.

§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.

§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Observations:

Based on a review of the facility's documents and staff interviews it was determined that the facility failed to implement a good faith effort to correct deficiencies cited during the survey ending January 9, 2026, by failing to complete the facility's plan of correction which indicated a direct in-service (training required by the state agency that is presented by an outside vendor) would be provided to all professional nursing staff as required. (all agency professional nursing staff).

Findings include:

A review of the facility's plan of correction for F678 J, cited during a survey on January 9, 2026, indicated that a direct in-service would be provided to all professional nursing staff.

During a review of facility documents including attendance records for a direct in - service conducted on 1/31/26, it was revealed that the documents provided no evidence of agency professional nursing staff being provided or attending the directed in-service.

During an interview on 1/23/26, at 2:30 pm the Director of Nursing confirmed that the facility failed to make certain that the direct in-service was provided and attended by all agency profession nursing staff as required.

28 Pa Code: 201.14(a)(b) Responsibility of Licensee

Plan of Correction - To be completed: 03/16/2026

No adverse events occurred due to the identified deficient practice related to F0865.

The directed in-service was completed on 1/31/26 and all in-house staff were educated appropriately. Agency staff completed CPR training but not the exact outside vendor directed in-service. This training has now been posted to agency platforms and agency nurses are not permitted to pick up any shifts until they have completed the education requirements.

The facility will do an ad hoc QAPI to ensure we are in complete compliance with the previously cited IJ. All staff members that play a role in staffing will be required to join.

An audit will be conducted to ensure ongoing compliance with education requirements for the next 30 days and results will be reviewed in April QAPI.

The facility will be compliant with citation by 3/16/26.

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