Pennsylvania Department of Health
 QUALITY LIFE SERVICES - SUGAR CREEK
Patient Care Inspection Results

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QUALITY LIFE SERVICES - SUGAR CREEK
Inspection Results For:

There are  139 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
QUALITY LIFE SERVICES - SUGAR CREEK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, and an incident completed on March 5, 2026, it was determined that Quality Life Services - Sugar Creek 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.




 Plan of Correction:


483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.
Observations:

Based on facility policy review, medical literature review, clinical record reviews, review of facility documents, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk which resulted in an Immediate Jeopardy situation for 40 of 107 residents.

Findings include:

Review of facility policy "Dysphagia (difficulty swallowing) Diets" dated 2/16/26, indicated the following:

Individuals with observed indicators of dysphagia (coughing, choking, delayed swallow, pocketing of food [storing food in cheeks, gums, without swallowing], inability to manipulate food in the mouth, wet gurgly voice, etc.) will be referred to the Speech Therapist (ST) for evaluation of dysphagia.The ST will evaluate the resident. Once a diagnosis has been made, the ST will work with the Registered Dietitian (RD) or designee to make appropriate recommendations to the physician for proper food and fluid consistency.Nursing care partners will notify the culinary director of needed consistency changes using the appropriate notification.The culinary department will be responsible for preparing and serving the diet and fluid consistency as ordered.Individuals needing a change in diet consistency may be placed on a mechanically altered diet. Diets should be adjusted to meet individual needs. For example, if the individual has difficulty chewing meat only, the meat may be ground or pureed, and other foods may be of regular consistency.Care will be taken to serve foods and fluids as ordered on the consistency altered diets and fluids.

Review of the International Dysphagia Diet Standardization Initiative (IDDSI) Framework, revised July 2019, provides definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia, which include the following descriptions:

Level 7 Easy to Chew foods must be able to break food apart easily with the side of a fork or spoon. To make sure the food is soft enough, press down on the fork until the thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain its shape.Level 5 Minced and Moist meats should be finely minced or chopped. Serve in mildly, moderately or extremely thick, smooth, sauce or gravy, draining excess. Use slot between fork prongs (4 millimeters) to determine whether minced pieces are the correct or incorrect size. Food should be soft enough to squash easily with fork or spoon. Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked. Sample should not be firm or sticky.Level 3 Moderately thick liquids should drip slowly or in dollops/strands through the slots of a fork. When a fork is pressed on the surface of Level 3 Moderately thick liquids, the tines/prongs of a fork do not leave a clear pattern on the surface.
Review of the clinical record revealed that Resident R1 was admitted to the facility on 4/5/24.

Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/21/25, indicated diagnoses of high blood pressure, malnutrition (lack of proper nutrition), and muscle wasting.

Review of Resident R1's clinical record revealed a progress note from Speech Therapy dated 10/4/25, that indicated that resident was seen for treatment of dysphagia.

Review of Resident R1's clinical record revealed a physician's order date 11/11/25, to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction.

Review of documentation provided by the facility dated 2/26/26, stated the following: Resident R1's 's daughter, immediately alerted nursing staff that the resident appeared to be choking. LPN (licensed practical nurse) and RN (registered nurse) were present outside the room at the medication cart and responded immediately. Upon entering the room, the resident was observed choking and unable to effectively clear food from the airway. The Heimlich maneuver (a lifesaving technique used to dislodge food or objects from a choking person's airway by forcing air up from the lungs) was immediately initiated by the RN. RN Supervisor was notified, and the CRNP (certified registered nurse practitioner) responded to bedside. Crash cart was brought to the room. Heimlich maneuver was performed for approximately one minute; however, the resident became cyanotic (a bluish discoloration of the skin resulting from inadequate oxygenation of the blood). When the obstruction was not relieved, the resident was carefully placed on a backboard, and abdominal thrusts were continued. Food material was visualized in the oral cavity, and suction was utilized to remove visible particles. Resident was on continuous oxygen via nasal cannula during the event. After the food bolus was dislodged, the resident exhibited shallow respirations with a pulse of 20 beats per minute. Daughter present at bedside. RN discussed condition and offered transfer to the emergency department. Daughter declined hospital transfer and requested comfort-focused care. Resident ceased to breathe at 12:40 p.m. with family present at bedside. At the time of the incident, the resident was served a hamburger that was not consistent with the physician-ordered diet.

Review of a written statement dated 2/26/26, indicated that Dietary Aide (DA) Employee E4 was interviewed regarding the above incident and stated that she was the server who placed the food onto the plate for Resident R1. Interviewer asked DA Employee E4 if she recalled placing a "7EC 5MM" (Level 7 Easy to Chew, Level 5 minced and moist meats) burger on Resident R1's plate, to which DA Employee E4 replied that " I can't honestly remember".

Review of a written statement dated 2/26/26, indicated that DA Employee E5 was also interviewed regarding the above incident. Interviewer asked DA Employee E5 if she could verify that Resident R1 received his appropriate diet, to which she replied, "I can't remember".

Review of a written statement dated 2/26/26, from Nurse Aide (NA) Employee E6 stated "This writer gave resident lunch tray while family was sitting in the room with him. I did not look at what was served. I saw the burger but did not realize it was not the right texture".

Review of Resident R1's plan of care did not include his physician ordered diet of to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction.

Review of the facility document "Diet Type Report" dated 3/3/26, revealed that the facility had 40 residents on altered texture diets (Level 7 Easy to chew, Level 5 minced and moist, pureed, and thickened liquids).

Review of five additional clinical records for residents that are ordered an altered texture diet revealed that four of the five did not have their altered texture diet listed as an approach in their plan of care (Resident R2, R3, R4, and R5).

During an interview on 3/3/26, at 1:03 p.m. the Nursing Home Administrator (NHA) provided a written outline of what has been implemented in the facility since the incident, which included: immediate education for all staff to check tray tickets (a slip of paper used by staff to communicate a resident's diet order, dislikes, and preferences) against tray before giving to resident. Also verify diet before giving drinks/snacks. Staff then sign off on the tray ticket to ensure they are correct. All meals being plated are monitored by cook and/or dietary supervisor are matching the diet orders on the meal tickets as well. IDDSI diets posted at all nurses' stations and dietary department. Binders at each nurses' station were already in place.

During an interview on 3/3/26, at 1:29 p.m. Speech Therapist (ST) Employee E7 indicated that she was aware of the above incident when Resident R1 received the wrong diet texture which resulted in him choking and dying. ST Employee E7 confirmed that she had worked with the resident in October 2025 for treatment of dysphagia, and had recommended the altered diet texture that he was ordered (Level 7 Easy to Chew with level 5 Minced and Moist Meats). ST Employee E7 confirmed that resident should not have received a regular hamburger, and that the meat should have been ground, and that the size of the meat particles should fit in between the prongs of a fork, and mixed with gravy, sauce or other condiments to make it moist and allow resident to safely chew and swallow. ST Employee E7 stated that the facility implemented the IDDSI diet system in 2019, and that staff was educated during the initiation of the new diet system, and that she made copes of the IDDSI diet to keep on the nursing units for future reference. ST Employee E4 added that staff was educated at the time the diets were implemented.

During an interview on 3/3/26, at 1:40 p.m. Registered Dietitian (RD) Employee E8 indicated that she is also aware of the above fatal incident regarding Resident R1, and confirmed that his diet order was "complicated" RD Employee E8 went on the explain the tray line process in the kitchen and stated that the "Starter" is the staff member at the beginning of the tray line and that they will read the diet orders out loud to communicate them to the other staff member who will be placing the food on the plate. The food on the plate/tray is then checked by a final staff member who will ensure that the food is accurate and appropriate for the prescribed diet. "If you are new, it's easy to miss, and hard to pay attention". RD Employee E8 confirmed that Resident R1 should not have received a regular hamburger because he was ordered level 5 minced and moist meats "It should have been ground with gravy". When State Agency (SA) asked of residents' diet orders are listed in their plan of care RD employee E8 stated "No, I just put in 'provide diet as ordered' because they are subject to change".

Review of the facility's tray tickets revealed that the facility uses abbreviations to communicate this information. For example, Resident R1's tray ticket on the date of the incident stated "7EC, 5MMM, NAS, Mod. Dislikes: banana, bread (wheat), broccoli, honeydew, hot dog, potato, sausage, spinach, tomato, and watermelon. Preferences: applesauce, hamburger, honey/Mod thk apple juice".

Review of the above tray ticket does not include what specific items to place on the tray such as Minced moist meat hamburger, etc.

During an interview on 3/3/26, at 4:27 p.m. The NHA and Director of Nursing (DON) were made aware that diet orders are not communicated via plan of care, and that tray tickets do not include full diet orders, and food items, which may have helped to contribute to Resident R1's receiving incorrect menu items, which was confirmed by the NHA. NHA made aware that immediate jeopardy situation exists for the additional 40 residents that receive altered texture diets, and an Immediate Jeopardy Template was provided.

During an interview on 3/3/26, at 4:41 p.m. Licensed Practical Nurse (LPN) Employee E9 stated that nursing staff have been doublechecking trays before they are passed to the resident. "Sometimes the diets are complicated, so you may have to look it up on the sheets." LPN Employee E9 referred to the cards that are now attached to the meal cart for reference on IDDSI diets. "We also have a binder at the desk with this information".

During an observation on 3/3/26, at 5:16 p.m. staff were noted to be reading each residents' tray ticket, checking the food on the tray to ensure it was the correct diet texture, and initialing the tray tickets while the food remained on the delivery cart.

During an interview on 3/3/26, at 5:16 NA Employee E10 stated that after someone checks the trays while still on the cart, NA are then double checking the tray to ensure its safety at the time of service. NA Employee E10 added that the incident with Resident R1 was "so scary", and that "everyone is taking the situation "very seriously".

On 3/3/26, at 7:25 p.m. an acceptable Corrective Action Plan was received which included the following interventions:

Staff passing trays are auditing food that is provided is matching the diet orders on the meal tickets. They are then signing off on the meal tickets to ensure they are correct. All meals being plated are monitored by the cook and/or dietary supervisors are matching the diet orders on the meal tickets as well.
2. All care plans will be reviewed and updated with current orders. NHA/designee will provide immediate education to RD, RNAC (Registered Nurse Assessment Coordinator), LPNAC (Licensed Practical Nurse Assessment Coordinator), and Dietary Manager on updating resident care plans with diets per physician's orders. This will be completed by Wednesday March 4th, 2026.

3. RD immediately went through current meal tickets to ensure that all residents' tickets match the physician orders to ensure the verbiage is more complete and not abbreviated for a better understanding by staff. This was completed on Tuesday Mach 3, 2026.

4. Education to be completed by NHA/designee to nursing/dietary/activities staff on diets that are used in this facility as well as any altered textures. This will be completed by Thursday, March 5th, 2026.

5. Education to be completed by RD/designee on reading and understanding the facility's tray tickets. This will be completed by Thursday March 5th, 2026.

6. Care plans will be audited against physician orders 5 times per week by NHA/designee to ensure accuracy.

7. Audits will be completed by NHA/designee to verify that staff understand the diets utilized and the altered textures. To be completed everyday times 5 days. Then 3 times per week for 4 weeks.

8. Dietary Manager and/or RD will conduct audits at time of plating meals to ensure the accuracy of diet texture per tray card/physician order. To be completed everyday times 5 days, then 3 times per week for 4 weeks.

9. Education to be completed by RD/designee to Dietary Manager on how to physically enter diets in the Food Service System (computer). This will be completed by Thursday March 5th, 2026.

10. A work group will be implemented 3/4/26 in morning to review Food Services Tray Card computer system versus other options.

11. All audits will be reviewed at an ad-hoc QAPI (quality assurance and performance improvement) meeting by Thursday March 5th, 2026.

Review of medical records conducted on 3/4/26, revealed that 107 of 107 residents in the facility had an updated care plan to include the current physician prescribed diet.

Review of tray tickets conducted on 3/4/26, revealed that all diet orders are written out in their entirety, (no longer abbreviated), and that they match the physician order for 107 of 107 residents. For example: 7EC is now "Easy Chew", and 5MMM is now "minced moist meat".

Review of tray audits conducted on 3/5/26, that were completed in dietary at time of tray line service were completed as required for three of three meals reviewed.

Review of tray audits conducted on 3/5/26, that were completed by nursing staff at time of service completed were completed as required for three of three meals reviewed.

Review of Care plan audits conducted on 3/5/26, revealed that they were completed as required on 3/5/26.

Review of Education documentation completed as follows:

IDDSI education completed on 130 of 142 employees- remaining to be educated prior to start of next shift.Tray ticket education completed on 150 of 163 -remaining to be educated prior to start of next shift.Entering diets education completed on 2 of 2 employees.Care plan education completed on 5 of 5 employees.
During interviews conducted from 3/4/26, at 10:58 a.m. through 3/5/26, at 12:30 p.m., 24 employees verified that they received the required education.

On 3/5/25, at 1:00 p.m. the Immediate Jeopardy was lifted when the action plan implementation was verified

During an interview on 3/5/26, at 1:49 p.m. NA Employee E11 stated that the revised tray tickets "are very helpful" and that staff have always been instructed to check trays before distributing them to a resident.

During an interview on 3/5/26, at 1:57 p.m. Dietary Manager (DM) Employee E12 stated that revised meal tickets may help to avoid making mistakes in the future, and that Resident R1 should have received a hamburger with minced meat mixed with gravy to keep it moist instead of a regular texture burger.

During an interview on 3/5/26, at 2:21 p.m. NA Employee E1 stated that the revised tray tickets are helpful with the complete diet order as often times families ask what the abbreviations mean.

During an interview on 3/5/26, at 4:01 p.m. the NHA confirmed that facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1) placing an additional 40 residents that had similar diet needs at risk (Residents R2, through R41)

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services





 Plan of Correction - To be completed: 04/09/2026

1. Investigation was completed on incident involving Resident R1 choking via root cause. Once investigation revealed wrong consistency, ERS submitted to PA DOH. PA SP, APS, and MD notified.
2. Rest of Facility:
a. Staff passing trays audited the food that was provided was matching the diet orders on the meal ticket. They then signed off on the meal tickets to ensure they are correct. Audits will continue for 1 rotating meal per day for 14 days. All meals being plated are monitored by cook and/or dietary supervisor are matching the diets orders on the meal tickets as well. Audits will continue for rotating 1 meal per day for1 4 days.
b. RD immediately went through current meal tickets to ensure that all resident's tickets match the physician orders to ensure the verbiage is more complete and not abbreviated. This was completed on March 3rd, 2026.
3. Education:
a. Education was completed by NHA/designee to nursing/dietary/activities staff on the diets that are used in this facility as well as any altered textures. This was completed March 5th, 2026. This will continue with all new direct care employees.
b. Education was completed by RD/designee on reading and understanding the facility's tray tickets. This was completed by March 5th, 2026. This will be continued will all new nursing/dietary/activities employees.
c. Education was provided by NHA/designee to all non-direct care workers on not giving residents any food or drink at any time. This was completed on March 5th, 2026. This will also be completed for all new non-direct care workers moving forward.
d. Education was completed by RD/designee to Dietary Manager on how to physically enter diets in the Gordon Food Service system. This was completed March 5th, 2026. This will also be completed for any new dietary supervisor who has access to update meal tickets moving forward.
e. Affinity Healthcare will provide education on April 2, 2026, outlining the review of the Federal regulation (s) cited during this survey, along with the accompanying guidelines, client's deficient practices outlined in the statement of deficiencies, client's approved plan of correction, and the currently accepted standards of professional practice related to F-805.
4. Audits:
a. Audits are completed and continuing to be completed by NHA/designee to verify that staff understand the diets utilized and the altered textures including non-direct caregivers not being allowed to assist with food or drink. To be completed Q Day times 5 days. Then 3 times per week for 4 weeks
b. Dietary Manager and/or RD conducted audits and will continue to conduct audits at time of plating meals to ensure the accuracy of diet texture per tray card/physician order. To be completed Q Day times 5 days. Then 3 times per week for 4 weeks.
5. Severity and details of Immediate Jeopardy relating to F0805 were discussed in an Ad-Hoc QAPI meeting on March 5th, 2026. All findings moving forward with above audits will be brought to regular QAPI meeting.


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on review of clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident nutrition care needs for five of six residents reviewed (Resident R1, R2, R3, R4, and R5).

Findings include:

Review of the International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) Framework, revised July 2019, provides definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia, which include the following descriptions:

Level 7 Easy to Chew foods must be able to break food apart easily with the side of a fork or spoon. To make sure the food is soft enough, press down on the fork until the thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain its shape.Level 5 Minced and Moist meats should be finely minced or chopped. Serve in mildly, moderately or extremely thick, smooth, sauce or gravy, draining excess. Use slot between fork prongs (4 millimeters) to determine whether minced pieces are the correct or incorrect size. Food should be soft enough to squash easily with fork or spoon. Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked. Sample should not be firm or sticky.Level 4 Pureed food is smooth with no lumps and minimal granulation. Cohesive enough to hold its shape on the spoon.Level 3 Moderately thick liquids should drip slowly or in dollops/strands through the slots of a fork. When a fork is pressed on the surface of Level 3 Moderately thick liquids, the tines/prongs of a fork do not leave a clear pattern on the surface.Level 2 Mildly thick liquids flows off a spoon. Sippable, pours quickly from a spoon, but slower than thin drinks.
Review of the clinical record revealed that Resident R1 was admitted to the facility on 4/5/24.

Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/21/25, indicated diagnoses of high blood pressure, malnutrition (lack of proper nutrition), and muscle wasting.

Review of Resident R1's clinical record revealed a physician's order dated 11/11/25, to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction.

Review of Resident R1's plan of care conducted on 3/3/26, did not include his physician ordered diet of to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction.

Review of clinical record revealed Resident R2 was admitted to the facility on 5/20/11.

Review of Resident R2's MDS dated 2/2/26, indicated diagnosis of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and hyperlipidemia (excess fat in the blood).

Review of Resident R2's clinical record revealed a physician's order dated 12/1/25, to provide a diet of 7 EC Easy to Chew texture, level 5 Minced and Moist Meats.

Review of Resident R2's plan of care conducted on 3/3/26, did not include the above physician ordered diet.

Review of clinical record revealed Resident R3 was admitted to the facility on 11/12/25.

Review of Resident R3's MDS dated 2/19/26, indicated diagnosis of high blood pressure, dysphagia (difficulty swallowing), and unsteadiness on feet.

Review of Resident R3's clinical record revealed a physician's order dated 2/25/26, to provide a diet of Reduced Concentrated Sweets, Minced and Moist texture.

Review of Resident R3's plan of care conducted on 3/3/26, did not include the above physician ordered diet.

Review of clinical record revealed Resident R4 was admitted to the facility on 3/3/22.

Review of Resident R4's MDS dated 12/24/25, indicated diagnosis of high blood pressure, dementia, and unsteadiness on feet.

Review of Resident R4's clinical record revealed a physician's order dated 12/2/25, to provide a diet of No Added Salt, level4 Pureed texture, level 2 mildly thick liquids.

Review of Resident R4's plan of care conducted on 3/3/26, did not include the above physician ordered diet.

Review of clinical record revealed Resident R5 was admitted to the facility on 12/31/24.

Review of Resident R5's MDS dated 1/2/26, indicated diagnosis of high blood pressure, hyperlipidemia, and unsteadiness on feet.

Review of Resident R5's clinical record revealed a physician's order dated 1/7/25, to provide a diet of No Added Salt, 7EC Easy to Chew texture, level 5 minced and moist meats.

Review of Resident R5's plan of care conducted on 3/3/26, did not include the above physician ordered diet.

During an interview on 3/3/26, at 1:40 p.m. Registered Dietitian (RD) Employee E8 was asked by State Agency (SA) if residents' diet orders are listed in their plan of care RD employee E8 stated "No, I just put in 'provide diet as ordered' because they are subject to change".

During an interview on 3/3/26, at 4:27 p.m. The Nursing Home Administrator confirmed that the facility failed to develop comprehensive care plans to meet resident nutrition care needs for five of six residents.

28 Pa Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.





 Plan of Correction - To be completed: 04/09/2026

1. IDT team updated all resident care plans to reflect diets per physician orders on 03/04/26.
2. NHA/designee provided education to RD, RNAC, LPNAC, and Dietary Manager on updating resident care plans with diets per physician's orders. This was completed on March 4th, 2026.
3. Care plans will be audited by NHA/designee 3 times per week for 14 days to ensure new physician's orders for diets have been added to the care plans.
4. Results will brought to QAPI meeting.


483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four nursing units (Willow Nursing Unit).

Findings include:

Review of facility policy "HIPAA/HITECH Administrative Policy" dated 2/16/26, indicated the facility is to protect residents' privacy rights and their individually identifiable health information as required by the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information, 45 CRF Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH) and all Federal regulations and interpretive guidelines promulgated thereunder.

During an observation on 3/4/26, at 2:01 p.m. the Willow Medication Cart at the nurses' station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information.

During an observation at 3/4/26, at 2:02 p.m. Nurse Aide (NA) Employee E1 walked up to the medication cart and closed the resident profile. NA Employee E1 stated, "The nurse just walked away from the cart and is a resident's room."

During an interview on 3/4/26, at 2:02 p.m. NA Employee E1 confirmed that the facility failed to maintain the confidentiality of residents' medical information on the Willow Nursing Unit.

During an interview on 3/5/26, at 2:18 p.m. information was disseminated to the Nursing Home Administrator and Director of Nursing that the facility failed to maintain the confidentiality of residents' medical information on one of four nursing units (Willow Nursing Unit).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.29(c.3) Resident Rights.
28 Pa. code: 211.5(b) Medical records.
28 Pa. Code: 211.12(d)(1) Nursing services.





 Plan of Correction - To be completed: 04/09/2026

1. A CNA noticed that computer screen was up and closed it immediately resolving issue.
2. Staff will be reeducated by NHA/designee to privacy/confidentiality of residents' personal and medical records.
3. Audits will be completed by NHA/designee 5 times per week for 1 weeks then 3 times per week times 2 weeks that there are no computer screens unattended with identifiable information on them.
4. Results will be brought to QAPI meeting.

483.70 REQUIREMENT Administration: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.
§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility when thefacility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk, and resulted in an Immediate Jeopardy situation for 40 of 107 residents.

Findings include:

The job description for the NHA specified the purpose of the position is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term care facilities and to ensure that the highest degree of resident care and services are delivered and maintained.

The job description for the DON specified the purpose of the position is to provide nursing management, set resident care standards for all direct care providers and provide completer supervision and management for the nursing department.

Based on findings identified in this report, the facility failed to provide an altered texture diet, as prescribed by the physician for one of 40 residents. This resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents with similar diet needs at risk which resulted in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.

During an interview on 3/3/26, at 4:27 p.m. the NHA and DON were notified that they failed to effectively manage the facility to prevent a choking incident that resulted in death, which created an immediate jeopardy situation for 40 of 107 residents.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.





 Plan of Correction - To be completed: 04/09/2026


1. Education will be provided to the Nursing Home Administrator and Director of Nursing on the International Dysphagia Diet Standardization Initiative guidelines by the Registered Dietician.
2. NHA and DON will complete Relias training on International Dysphagia Diet Standardization Initiative protocol.
3. NHA and DON will participate in the mandatory in servicing provided by Affinity Healthcare on April 2nd, 2026.
4. Registered Dietician will be at the facility 3 days per week for the next 30 days to monitor the overall education and performance of the dietary department.
5. NHA and DON will be educated on their job description by the Clinical Services Specialist/designee to ensure understanding of their responsibilities.
6. Audits:
a. Audits are completed and continuing to be completed by NHA/designee to verify that staff understand the diets utilized and the altered textures including non-direct caregivers not being allowed to assist with food or drink. To be completed Q Day times 5 days. Then 3 times per week for 4 weeks.
b. Dietary Manager and/or RD conducted audits and will continue to conduct audits at time of plating meals to ensure the accuracy of diet texture per tray card/physician order. To be completed Q Day times 5 days. Then 3 times per week for 4 weeks.
7. Results will brought to QAPI meeting.

§ 201.19(6) LICENSURE Personnel policies and procedures.:State only Deficiency.
(6) Documentation of the employee's orientation to the facility and the employee's assigned position prior to or within 1 week of the employee's start date.

Observations:

Based on a review of personnel records and staff interview, it was determined that the facility failed to provide an employee orientation to the facility for one of five personnel files reviewed (Nurse Aide (NA) Employee E2).

Findings include:

Review of NA Employee E2's personnel file revealed a hire date of 1/3/26. Review of the personnel file did not include evidence of an employee orientation to the facility.

During an interview on 3/5/26, at 2:10 p.m. Human Resources Employee E3 confirmed that the facility failed to provide an employee orientation to the facility for one of five personnel files reviewed (NA Employee E2).





 Plan of Correction - To be completed: 04/09/2026

1. HR will audit new staff that have been at the facility over the past 14 days to ensure facility orientation has been completed.
2. HR/Designee will attempt to contact staff that have not received facility orientation over the past 14 days to come to facility to complete.
3. HR Director and Hiring Department Managers will be reeducated by Corporate HR/designee on completion of orientation to facility upon hire within 1 week of employee start date.
4. Audit will be completed by HR Director for completion of orientation to facility for new hires for 14 days.
5. Results will be brought to QAPI Meeting.


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