Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint at Immaculate Mary Center for Rehabilitation completed on November 19, 2019, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.


Based on a review of facility documentation and an interview with facility staff, it was determined that the facility failed to follow reporting procedures for one of one resident reviewed who sustained a serious physical injury. (Resident R1)

Findings include:

The Older Adult Protective Services Act of November 6, 1983, amended by Act 13-1997, Chapter 7, section 701, requires that all administrators or employees who have reasonable cause to suspect that a resident was a victim of serious physical injury, serious bodily injury, sexual abuse or that a death was suspicious, are required to make an immediate report to the Protective Services Agency, The Pennsylvania Department of Aging and local law enforcement officials.

Review of a reportable event submitted by the facility on August 26, 2019, revealed that Resident R1 was observed with discoloration and pain to her left lower extremity. An X-ray revealed fractures of the left distal shafts of the tibia and fibula (the two long bones in the lower leg). The resident was transferred to the hospital and was admitted for the fracture. The reportable also indicated that the resident was contracted (a condition often leading to deformity and rigidity of joints), sat in a broada chair when out of bed and per the head radiologist, the possible cause of the fracture could be related to the residents foot getting caught while turning and repositioning.

There was no documentation to indicate the Pennsylvania Department of Aging, in accordance with the Older Adult Protective Services Act, was notified as required.

Interview with the Administrator and Director of Nurses on November 19, 2019 at 1:30 p.m., confirmed the Pennsylvania Department of Aging was not notified as required.

28 Pa Code 201.18 (b)(1)(3)(e)(1) Management
Previously cited 8/12/19, 3/21/19 and 3/12/19

28 Pa Code 201.18 (e)(1) Management
Previously cited 8/24/18

 Plan of Correction - To be completed: 12/05/2019

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1. Resident R-1 injury was investigated and reported to local Dept of Health via online event reporting system, and also Philadelphia Corporation of aging.
2. All residents with serious injury going forward will be reported additionally to Pennsylvania Dept of Aging.
3. All four leadership team members that conduct investigations and manage the reporting of injuries and allegations have been educated on the requirement specifics for reporting to the Pennsylvania Dept of Aging.
4. The NHA or designee will review all reportable events and allegations to assure all notifications to various parties (police, event reporting site, Philadelphia Aging and Pennsylvania Dept of Aging ) are all completed timely as directed.

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