Pennsylvania Department of Health
WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 154 surveys for this facility. Please select a date to view the survey results.

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WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to a Complaint, completed on May 13, 2025, it was detrmined that WeCare At Sycamore Rehabilitation And Nursing Center 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 process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 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 a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding neurological assessments for one of five residents reviewed.

Findings include:

The current facility policy entitled "Neurological Assessment," revealed neurological assessments are indicated following an unwitnessed fall. When assessing neurological status, always include frequent vital signs, particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures) as this may be indicative of increasing intracranial pressure. Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately.

Closed clinical record review for Resident CR1 revealed nursing documentation dated April 24, 2025, at 10:32 PM noting Resident CR1 was found in her bathroom, face down on the floor. The registered nurse assessed Resident CR1 before moving her, noting a 4 centimeter (cm) by 3.5 cm laceration to Resident CR1's right elbow and a 0.75 by 0.25 cm laceration to her left elbow. The registered nurse assessed Resident CR1's neurological status and cleaned her lacerations with wound cleanser while applying pressure to stop the bleeding. The registered nurse called the physician on call. The on call physician ordered the nurse to hold Resident CR1's morning dose of Eliquis (medication used as a blood thinner), talk with Resident CR1's physician in the morning, and if there are any changes in Resident CR1's neurological status to send her to the emergency room.

Review of the facility's investigation dated April 24, 2025, at 9:30 PM revealed Employee 2's (nurse aide) witness statement indicated that she provided care to Resident CR1 at 9:00 PM while Resident CR1 was in bed. Employee 2's statement noted that another resident came to the nurse's station and stated Resident CR1 was on the floor in her bathroom.

Nursing documentation dated April 25, 2025, at 6:38 AM revealed Resident CR1 was found deceased at 6:34 AM and pronounced at this time. Resident CR1's death certificate indicated the main cause of death was chronic diastolic heart failure (decreased blood flow caused by high blood pressure).

Review of Resident CR1's Neurological Assessment Form revealed that nursing staff completed her neurological assessments at 9:30 PM, 10:00 PM, 10:30 PM, and 11:00 PM. There were no other assessments of Resident CR1's neurological status documented. The facility failed to document neurological assessments at 12 AM, 1 AM, 3 AM, and 5 AM.

Interview with Employee 1 (registered nurse) on May 13, 2025, at 12:28 PM confirmed these findings. Employee 1 revealed if a resident has an unwitnessed fall, staff are to complete neurological assessments on the resident every 30 minutes for first two hours, then every 60 minutes for two hours, then every two hours twice, then every four hours twice, and every eight hours twice.

Interview with the Nursing Home Administrator on May 13, 2025, at 3:11 PM confirmed these findings for Resident CR1.

The facility failed to provide the highest practical care related to neurological assessments for Resident CR1.

483.25 Quality of Care
Previously cited deficiency 2/21/25

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

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

Resident CR1 no longer resides in the facility
The DON and or designee will review the last 30 days of unwitnessed falls for neurological assessments
The Licensed nursing staff will be educated on the policy and procedures related to neurological assessments
The DON or designee will audit 20 % of unwitnessed falls to assure neurological assessments have been completed weekly x 4 weeks and monthly x 2 months
These audits will be reviewed at the QAPI meeting for further recommendations

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