Pennsylvania Department of Health
NAAMANS CREEK COUNTRY MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NAAMANS CREEK COUNTRY MANOR
Inspection Results For:

There are 96 surveys for this facility. Please select a date to view the survey results.

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NAAMANS CREEK COUNTRY MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey and a complaint investigation survey completed on May 02, 2025 , at Naaman's Creek Country Manor, it was determined the facility was not in compliance under the 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 process.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observations, review of facility policies, and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety for two of two nursing units (First Floor and Second Floor nursing units).

Findings include:

Review of the facility policy, "Dry Food Storage" dated May 30, 2025, revealed, " dry food storage is necessary for foods that do not require refrigeration or freezing and requires proper guidelines. All food items must be dated, labeled and sealed. Rotate products to ensure that the oldest inventory is used first."

Observation on April 29, 2025, at 9:45 a.m. of the second-floor kitchen dry food storage area revealed expired used by dates for multiple loaves of bread and packages of buns. This included, 1 package of hot dog buns use by dated April 8, 2025, 1 loaf of wheat bread use by dated April 27, 2025, 1 loaf of raisin bread use by dated April 25, 2025, 5 packages of hamburger buns use by dated April 26, 2025, of which 2 packages revealed black and green spots on the buns, and 9 loaves of rye bread with no visible received or use by dates.

Interview with Director of Dietary Services, Employee E3, on April 29, 2025, at 9:45 a.m. confirmed that items were not properly labeled or dated, items were expired, and the 2 packages of hamburger buns had visible black and green spots on them.

The facility failed to ensure that food was stored properly, labeled and dated according to professional standards.

28 Pa Code 201.18(b)(1) Management

Plan of Correction - To be completed: 06/17/2025

1. Bread was discarded

2. Dietary Director or designee will complete audit of dry storage to verify bread is not outdated.

3. Dietary staff was re-educated on Dry Food Storage policy

4. Dietary Director or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify items are labeled and dated being as per policy. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 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.

Plan of Correction - To be completed: 06/17/2025

1. Resident 13 and 66 were discharged. Resident 14 was re-weighed. Physician aware of weight gain.

2. DON or designee will complete audit on current residents that have daily weights orders and/or medication with parameters to verify physician orders are followed.

3. Licensed staff was re-educated on physician orders policy and weight policy

4. DON or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that physician orders are being followed. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

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.

Plan of Correction - To be completed: 06/17/2025

1. Resident 66 and 175 were discharged. Resident 63 was re-weighed.

2. DON or designee will review current resident's last two weights to verify weight policy and physician notification is being followed.

3. Licensed staff was re-educated on Weight policy

4. DON or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that Weight policy is being followed. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Chemical Restraints:

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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on review of clinical records and staff interview it was determined that the facility failed to ensure that one resident out of 24 sampled was free of chemical restraints (Resident 63).

Findings include:

A review of Resident 63's clinical record revealed admission to the facility on January 24, 2025, with diagnoses to include cerebral infraction (pathologic process that results in an area of necrotic tissue in the brain), cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

An admission Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated January 24, 2025, indicated that the resident is moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8-12 represents moderate cognitive impairment).

A review of resident 63's clinical record revealed that the resident was prescribed Xanax (antianxiety, used to treat anxiety disorders and anxiety caused by depression) Oral Tablet 0.25 MG (milligrams) PRN (as needed) every 8 hours for 30 days, with a start date of February 14, 2025.

Additional review of the resident's clinal record revealed an order to administer "Nonpharmacological Intervention(s) used before PRN Pain Medication or before PRN antidepressant, antianxiety, antipsychotic or sedative/hypnotic medication Document by number:1 Reposition for comfort 2 massage 3 involve in activity/alt. activity to divert 4 provide quiet setting with reduced stimuli as needed 5 relaxation technique 6 music 7 remove from area 8 direction/distraction" with a start date of January 24, 2025.

Review of Resident 63's medication administration record (MAR) for the month of March 2025, revealed the facility administered the Xanax to Resident 63 on March 5th 2025, March 12, 2025 and March 14, 2025.

Further review of Resdient 63's MAR for March 2025 revealed the facility did not attempt any Nonpharmacological Interventions prior to administering Xanax to Resident 63.

Review of Resident 63's progress notes failed to reveal any documentation of nonpharmacological Intervention being attempted prior to the administration of Xanax.

An interview conducted with the Nursing Home Administrator (NHA) on May 2nd, 2025, at 11:25 a.m. confirmed the facility failed to attempt nonpharmacological Intervention prior to administering antianxiety medication to Resident 63.

28 Pa. Code 211.8 (c.1)(1)(e) Use of Restraints.

28 Pa. Code 211.5 (f) Medical records

Plan of Correction - To be completed: 06/17/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1. Resident 63's PRN Xanax order was discontinued.

2. DON or designee will complete audit on current residents who are on PRN medication to verify NPIs were offered prior to medication.

3. Licensed staff was re-educated on Psychotropic medication policy and Pain Management policy.

4. DON or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that NPIs are attempted prior to administering PRN medication. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on clinical record review and staff interviews, it was determined that the pharmacy failed to ensure medication for wound care was available for one of the four residents reviewed (Resident 175).

Findings include:

A review of Resident 175's physician order dated April 29, 2025, revealed an order for Santyl (A topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) ointment, apply nickel thick layer to the sacrum (The triangular bone just below the lumbar vertebrae) wound bed after cleansing with normal saline solution, cover with foam dressing once a day and as needed. May use Medihoney (A dressing that aids and support debridement and a moist wound healing environment in acute and chronic wounds and burns.) until Santyl arrives.

An observation of the wound care treatment conducted on May 1, 2025, at 9:45 a.m., revealed that Medihoney treatment was used for the sacral wound instead of the Santyl.

An interview with licensed nurse Employee E4 conducted on May 1, 2025, at 9:50 a.m., revealed that the facility was still using Medihoney instead of Santyl because the pharmacy had not delivered the medication yet.

An interview conducted with the Assistant Director of Nursing on May 1, 2025, at 1:00 p.m., revealed that the medication order was sent to the pharmacy on April 29, 2025. A medication follow-up was made on April 30, 2025, and was informed that the medication would be delivered. On May 1, 2025, after another follow-up call, pharmacy representative [name of the pharmacist] reported that the medication delay was due to the absence of wound dimension documents. Records revealed order sent had dimension documents but was missed by the pharmacy.

The pharmacy failed to ensure Santyl's medication for Resident 175's sacral wound was made available timely.

28 Pa. Code 211.9(h) Pharmacy services.

28 Pa Code 211.12(c)(d)(3) Nursing Services
Previously cites 5/17/25

Plan of Correction - To be completed: 06/17/2025

1. Resident 175 was discharged

2. DON or designee will complete audit on wound treatment orders to verify ordered supplies are available.

3. License staff were re-educated on pharmacy services policy

4. DON or designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that medication/ointments are received as per policy. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X 3 months.

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