Pennsylvania Department of Health
RITTENHOUSE POST ACUTE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 58 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.


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

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and a State Licensure Survey, completed on May 15, 2025, it was determined that Rittenhouse Post Acute, was not in compliance with 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 related to the health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

Resident R65 has been discharged from the facility.
The facility will complete an audit of current resident transfer/transport status to validate resident care plans reflect the current transfer/transport status. Variances were addressed at the time of the audit and placed on the facility audit tool.
The nursing staff will be educated on the importance validating resident care plans match the current transfer/transport status.
NHA/Designee will complete random audits 2x per week for 3 weeks and then monthly for 3 months of resident care plans to reflect the current transfer/transportation status.
The results of the audits will be submitted to the quality assurance performance improvement committee monthly for review and recommendations, including the need for further audits if indicated based on the audit findings.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-Coverage (NOMNC) for one of three residents reviewed (Resident R66).

Findings include:

Review of facility documentation revealed no evidence that the Notification of Medicare Non-coverage was provided to Resident R66.

Interview with Director of Social Services, Employee E3 conducted on May 14, 2025, at 11:05 a.m. confirmed that she was responsible for sending the Notice of Medicare Non-Coverage to residents who were discharged from Medication Part A with remaining Medicare days.

Continued interview with Social Services, Employee E3 revealed that Resident R66 was scheduled to leave at a planned date of September 27, 2024, but requested to leave on September 25, 2025. Further, Employee E3 also revealed that Resident R66 informed Employee E3 of his wishes to go home earlier a few days before September 25, 2025. Further, Employee E3 also revealed that she informed Rehab about Resident R66 wishing to leave earlier, and that rehab cleared the resident to go home. Employee E3 confirmed that she did not provide Resident R66 with a Notification of Medicare Non-coverage. Further Employee E3 also confirmed that should have been provided to Resident R66 with a Notification of Medicare Non-coverage.

28 Pa. Code 201.18(b)(1) Management

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

Resident R66 has been discharged from the facility.
The facility will complete an audit of current residents to identify if any resident is due to receive a Notice of Medicare Non-Coverage. Variances were addressed at the time of the audit and placed on the facility audit tool.
The Social Service Director will be educated on the importance of validating any resident who has been issued a Notice of Medicare Non-Coverage receives a copy of the notice.
NHA/Designee will complete random audits 2x per week for 3 weeks and then monthly for 3 months of any resident who has been issued a Notice of Medicare Non-Coverage, has received a copy of the notice. The results of the audits will be submitted to the quality assurance performance improvement committee monthly for review and recommendations, including the need for further audits if indicated based on the audit findings.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 observations, review of facility policy, review of clinical records, and staff in our view, it was determined that the facility failed to develop and implement a person center and comprehensive care plan related to resident's nutritional needs and weight loss for one resident. (Resident R1)

Findings include:

Review of facility policy titled "Care Plans, Comprehensive Person Centered" dated March 2022, revealed that a comprehensive person center care plan includes measurable objectives and timetables to meet all resident's physical, psychosocial and functional needs. The care plan includes the resident's goals upon admission, reflects currently recognized standards of practice for problem areas and conditions. When possible, the care plan interventions address the underlying source of the problem areas. Assessments of the residents are ongoing, and care plans are reassessed as information about the resident and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition.

Review of policy titled "Weight Assessment and Intervention" dated March 2022, revealed that resident weights are monitored for undesirable or unintended weight loss or gains. Undesirable weight change is evaluated, this evaluation includes recent target weight range, resident's calorie protein and other nutrient needs compared to the resident's current intake, the relationship between current medical condition or clinical situation and recent fluctuations in weight and whether and to what extent weight stabilizing or improvement can be anticipated. Care planning for weight loss or impaired nutrition is a multi-disciplinary effort and includes the physician nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plan shall address, to extent possible the identified cause of weight loss, goals and benchmarks for improvement, and time frames and perimeters for modern monitoring and reassessment. Interventions for undesirable weight loss are based on careful consideration of the following; resident choice preferences, common nutrition, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite, chewing and swallowing abnormalities, medications that may interfere with appetite, the use of supplementation or feeding tubes and end of life directives.

Review of Review of resident R 1's admission minimum data set (MDS- a federal mandated assessment tool for all residents) dated December April 23, 2025, revealed that resident R1 was admitted into the facility April 16, 2025, 2024 with diagnosis' including Coronary artery disease( a heart disease that happens when coronary arteries cannot supply the heart with enough blood, oxygen and nutrients), hypertension(high blood pressure-a condition where the force of blood in the heart is consistently too high), diabetes(the body does not produce enough insulin or cannot properly use insulin, leading to high blood sugar levels), aphasia(inability to swallow ), malnutrition(Lack of proper nutrition ), and depression(persistent feeling of sadness and changes of how you think, sleep, eat , and act). Resident assessment with a cognitive BIMS (brief interview for mental status) score of 11, indicating the resident is moderate cognitive impairment.
Review of resident's weight summary dated April 16th, 2025, resident was recorded as being 118.0 pounds admission, April 23rd, 2025, resident reported being 107.6, indicating a 10.4-pound weight loss. After two weeks the resident was weighted again and was documented as 102.8 pounds, indicating a 4.8-pound weight loss.

Review of resident R1's care plan revealed that Resident is at risk for malnutrition related to muscle fat wasting on NFPE (nutrition focused physical exam), need for modified food texture food, need for an ONS (oral nutrition supplements), altered nutrition related labs, increased metabolic needs and chronic medical diagnosis which was initiated April 22, 2025. The intervention for this focus was to provide a regular, thin liquid diet that noted "I prefer the following foods: pescatarian diet" A diet that is free of meat and chicken, primarily a plant-based diet with fish consumption.

Further review of resident R1's care plan revealed no focus or intervention and goals of resident 's documented weight loss.

Continued review of resident R1's care plan revealed there was no interventions of resident's "preference" of pescatarian diet and supplemental needs that accompany this diet.

Interview with dietitian, employee E5, conducted on May 14, 2025, at 10:53 AM confirmed that the resident has documented weight loss which has not been included in the resident care plan. Employee E5 stated that she has worked with the kitchen staff to develop a pescatarian diet for resident R1. There is no indication that the facility has any documented menu choices for pescatarian residents' preferences.

28 Pa Code 211.10(c) Resident care policies

28 Pa Code 211.12(d)(5) Nursing service

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

Resident R1 Care Plan has been updated to address a documented weight loss and a "Pescatarian diet" preference.
The facility will complete an audit of current residents' care plans to validate residents with a documented weight loss and or a diet preference has been addressed. Variances were addressed at the time of the audit and placed on the facility audit tool.
The Licensed Nurses and Dietician will be educated on the importance of developing a comprehensive care plan for each resident as it relates to a resident's weight loss or a documented diet preference.
NHA/Designee will complete random audits 2x per week for 3 weeks and then monthly for 3 months of resident care plans to validate residents with a documented weight loss and or diet preference has been addressed. The results of the audits will be submitted to the quality assurance performance improvement committee monthly for review and recommendations, including the need for further audits if indicated based on the audit findings.

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.

Observations:

Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to monitor, implement and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutrition for two of sixteen resident records reviewed. (Residents R61 and Resident R1)
Findings include:

Review of facility policy on "Weight Assessment and Intervention" dated March 2022, section "Policy Statement" Resident weights are monitored for undesirable or unintended weight loss or gain. Section "Policy Interpretation and Implementation" Weight Assessment #1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. #2. Weights are recorded in each unit's weight record chart and in the individual's medical record. #3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. #4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. #5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. Section "Evaluation" #1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for "significant" weight change has been met. The evaluation includes a. the resident's target weight range (including rationale if different from ideal body weight); b. the resident's calorie, protein, and other nutrient needs compared with the resident's current intake; c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. whether and to what extent weight stabilization or improvement can be anticipated.

Review of Resident R61's clinical record revealed that Resident R61 was admitted to the facility on May 3, 2025, with diagnoses of Fracture of Lumbosacral spine ad pelvis.

Review of resident R61's weight record revealed the following: On May 3, 2025, Resident R61's weight was 179.0 lbs. (pounds), On May 6, 2025, Resident R61's weight was 171.8 lbs., On May 13, 2025, Resident R61's weight was 169.8 lbs.

Further review of Resident R61's clinical record revealed that there were no dietary notes until May 14, 2025. Review of Dietary note dated May 14, 2025, revealed a Weight Change Note as follow: WEIGHT CHANGE: Value: 169.8 -5.0% change [ 5.1%, 9.2] reweigh pending.

Further review of Resident R61's weight record revealed that no reweight was done. Last recorded weight was on May 13, 2025, at 169.8 lbs.

Further, review of Resident R61's clinical record revealed that there was no documented evidence that the weight loss was addressed by the dietician Employee E5 or by staff at the facility.

Review of the nutrition care plan revealed that Resident R61 was at risk for malnutrition related to muscle/fat wasting, need for therapeutic diet, altered nutrition-related labs, increased metabolic needs, and chronic medical Dx. Date Initiated: 05/05/2025

Further review of Resident R61's care plan revealed that the care plan was not updated to address the significant weight loss observed on May 3, 2025, May 6, 2025, and May 13, 2025.

Interview with Dietician Employee E5 conducted on May 14, 2025, at 10:53 AM confirmed that Resident R61 had a 9.2 lbs. weight loss or 5.14% weight loss from May 3, 2025, to May 13, 2025, a 5.14%weight loss in 10 days. Further Employee E5 confirmed that she has not seen Resident R61 until May 14, 2025.

Review of Review of resident R 1's admission minimum data set (MDS- a federal mandated assessment tool for all residents) dated December April 23, 2025, revealed that resident R1 was admitted into the facility April 16, 2025, 2024 with diagnosis' including Coronary artery disease( a heart disease that happens when coronary arteries cannot supply the heart with enough blood, oxygen and nutrients), hypertension(high blood pressure-a condition where the force of blood in the heart is consistently too high), diabetes(the body does not produce enough insulin or cannot properly use insulin, leading to high blood sugar levels), aphagia(inability to swallow ), malnutrition(Lack of proper nutrition ), and depression(persistent feeling of sadness and changes of how you think, sleep, eat , and act). Resident assessment with a cognitive BIMS (brief interview for mental status) score of 11, indicating the resident is moderate cognitive impairment.

Review of resident R1's hospital record prior to entering the facility, dated April 15, 2025, revealed resident presented to the emergency room on April 13, 2025, following a fall with progressively worsening lower back pain., she was treated conservatively with pain control and early mobilization and was discharged on April 16th to a skilled nursing facility. This document included resident's current weight as 53.5 kilograms,118 pounds dated April 15, 2025.

Review of resident nutritional risk assessment dated April 21st, 2025, revealed resident is at risk for malnutrition with a score of 11.0. The resident's BMI (body mass index-measure of body fat based on height and weight) was 23.8(indicating resident is within normal body weight). Resident's most recent weight documented as 118 pounds on the admission April 16th, 2025. The resident estimated calories are 1501 to 1770. Resident R1's documented food intake revealed that intake meals 51 to 75% of estimated needs. The resident report she is pescatarian RD (registered dietician) will update diet preferences via food service director.

Continue review of this assessment document revealed that this resident is at risk for malnutrition she presents a need for modified food texture, need for ONS(oral nutritional supplement), altered nutrition related to labs, increased metabolic needs, and chronic medical diagnosis with a plan to offer ensure plus 8 ounce via PO twice a day for low protein and albumin provides 350K Cal and 20 grams of protein.

Review of resident recorded weights revealed on April 16, 2025(admission resident weight recorded as 118.0, April 23, 2025, resident's weight recorded as 107.6 pounds, May 7, 2025, resident's weight recorded as 102.8 pounds.

Review of resident clinical record dietary notes revealed that on April 30, 2025, resident R1 triggered for weight warning indication that resident R 1 has sustained a weight loss of 10.4 pounds 8.8% change. REWEIGHT PENDING. There was no indication that resident R1 was reweighed.

Further review of resident R 1 clinical record dietary notes dated May 7, 2025, revealed that resident R 1 triggered weight warning indicating resident now recorded weight of 102.8, 12.7 % one-month weight loss. The RD met with resident to address recent significant weight change. Residents reported that occasionally her family provides her own food. RD offered Ensure clear once a day. Full comprehensive assessment to follow.

Further review of resident R 1 clinical record dietary notes dated May 14, 2025, revealed
Note Text: WEIGHT CHANGE: Value: 102.9Vital Date: 2025-05-13 14:13:00.0MDS: -5.0% change over 30 day(s) [ 12.7%, 15.0]-5.0% change [ 12.8% , 15.1 ]-7.5% change [ 12.8% , 15.1 ]-10.0% change [ 12.8% , 15.1 ]reweight pending. No indication that resident R 1 was reweighed.

Interview with resident R 1 on May 13, 2025, at 10:48 a.m. revealed that this resident has concerns of diet and weight loss. Resident R1 stated that she has not been provided her dietary preference of a pescatarian diet.

Interview with Resident R 1 on May 15, 2025, revealed that this resident was served a plate of French fries the previous evening for dinner.

Interview with dietitian employee E5 conducted on May 14, 2025, at 10:53 AM revealed that she is aware of resident R1's recent weight loss, she believed the weight loss has been attributed to healing process, and the initial weight recorded may have been inaccurate. This employee was unable to provide any meal tracking or nutritional requirements for this resident. Employee E5 and has confirmed that a full comprehensive assessment addressing the residents weight loss, or any documented interdisciplinary team notification has not been completed.

28 Pa. Code 211.12(c) Resident care policies

28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

Resident R1 Care Plan has been updated to address any documented weight loss.
Resident R61 has been discharged from the facility.
The facility will complete an audit of current residents to validate nutritional needs are assessed and interventions are care planned. Variances were addressed at the time of the audit and placed on the facility audit tool.
The Licensed Nurses and Dietician will be educated on assessing and developing a comprehensive care plan for each resident as it relates to a resident's weight loss.
NHA/Designee will complete random audits 2x per week for 3 weeks and then monthly for 3 months to validate nutritional needs are assessed and interventions are care planned. The results of the audits will be submitted to the quality assurance performance improvement committee monthly for review and recommendations, including the need for further audits if indicated based on the audit findings.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of residents for two of two residents with diagnosis of PTSD (post-traumatic stress disorder). (Resident R60 and Resident R63)

Findings include:

Review of facility policy on "Trauma Informed Care and Culturally Competent Care" dated August 2022 revealed that under section "Purpose" To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Under section "General Guidelines" 1. Traumatic events which may affect residents during their lifetime include: a. physical, sexual and emotional abuse; b. neglect; c. interpersonal or community violence; d. serious injury or illness; e. bullying; f. forced displacement; g. racism; h. war; and i. generational or historical trauma. # 2. Trauma-informed care is based on Trauma-Informed and Resilience Oriented (TIRO), evidence-based and emerging best practices. 3. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. 4. Triggers are highly individualized. Under section "Organizational Strategies" #1. Evaluate the need for trauma-informed practices as part of the facility assessment. #2. Utilize the facility assessment to identify the cultural characteristics of the resident population, including language, religious or cultural practices, values and preferences. #3. Develop an organizational culture that supports all Trauma-Informed and Resilience Oriented (TIRO) domains. These include: a. universal and early screening and assessment; b. resident-centered care and services; e. safe and secure environments; g. ongoing performance improvement and evaluation. #7. Establish an environment of physical and emotional safety for residents and staff. Under section "Resident Screening" #1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. #2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive. #3. Screening may include information such as: a. trauma history, including type, severity and duration; b. depression, trauma-related or dissociative symptoms; c. risk for safety (self or others); d. concerns with sleep or intrusive experiences; e. behavioral, interpersonal or developmental concerns; f. historical mental health diagnosis; g. substance use; h. protective factors and resources available; and i. physical health concerns. 4. Utilize initial screening to identify the need for further assessment and care. Unser section "Resident Assessment" #1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. #2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. #3. Use assessment tools that are facility-approved and specific to the resident population.

Review of Resident R60's clinical record revealed that Resident R60 was admitted to the facility on April 30, 2025, with diagnoses of but not limited to PTSD (Post Traumatic Stress Disorder).

Review of Resident R60's admission MDS (Minimum Data Set-a federally required resident assessment completed at a specific interval) dated May 7, 2025, Section I - Active Diagnoses, I6100. Post Traumatic Stress Disorder (PTSD) was marked "X" indicating that resident had a diagnosis of PTSD.

Further review of Resident R60's clinical record revealed no documented evidence that an assessment related to PTSD was conducted on Resident R60, Furtherer, there was no documented evidence that Resident R60 received services to address Resident R60's diagnoses of PTSD.

Further review of Resident R60's clinical record revealed a psych note dated May 5, 2025. Review of the psych note dated May 5, 2025, revealed that Resident R60 was seen due to psychotropic use while in a rehabilitation setting. Further, there was no mention of Resident R60's diagnoses of PTSD in the psych evaluation.

Review of Resident R60's care plans revealed no care plan addressing Resident R60's PTSD diagnoses.

Review of Resident R63's clinical record revealed that Resident R63 was admitted to the facility on May 1, 2025, with diagnoses of but not limited to PTSD (Post Traumatic Stress Disorder).

Further review of Resident R63's clinical record revealed no documented evidence that an assessment related to PTSD was conducted on Resident R63. Furtherer, there was no documented evidence that Resident R63 received services to address Resident R63's diagnoses of PTSD.

Review of resident R63's care plans revealed no care plan addressing Resident R63's PTSD diagnoses.

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

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."
Resident R60 and R63 Care plans for trauma-informed care have been updated.
The facility will complete an audit of current residents to validate residents with a diagnosis of Post Traumatic Stress Disorder (PTSD) are care planned. Variances were addressed at the time of the audit and placed on the facility audit tool.

The Social Service Director will be educated on the importance of making sure that any resident with a diagnosis of PTSD has a care plan addressing trauma-informed care.
NHA/Designee will complete random audits 2x per week for 3 weeks and then monthly for 3 months of residents' clinical records to identify any resident with PTSD, has a care plan for trauma-informed care. The results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations, including any indication of the need for further audits based on the audit findings.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure one resident was free from significant medication error for 1 of 3 resident reviewed. (Resident R1)

Findings include:

Review a facility policy titled "Administering Medications" dated April 2019, revealed that all medications are administered in accordance with prescriber orders and residents may self-administer their medication only if the attending physician comment in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Review of the National Institute of Health article titled "Magnesium Fact Sheet for health professionals" dated June 2, 2022, revealed magnesium is a nutrient that the body needs to stay healthy magnesium is an important for many processes in the body including regulating muscle and nerve function, blood sugar levels, and blood pressure and making protein, bone and DNA. Recommended intakes for magnesium and other nutrients are provided in a dietary reference intakes developed by the Food and Nutrition Board at the Institute of Medicine and the National Academies. Health risks from excessive magnesium too much magnesium from foods does not pose a health risk in healthy individuals because the kidneys eliminate excess amounts in urine however high doses of magnesium from dietary supplements or medications often result in diarrhea and can be accompanied by nausea and abdominal cramping. Very large doses of magnesium containing lads live in and acids providing more than 5000 milligrams a day have been associated with magnesium toxicity including fatal hyper magnesium Mia. The risk of magnesium toxicity increases with impaired renal function or kidney failure. Several types of medication that has potential to interact with magnesium supplements or affect the magnesium status.

Review of Resident R1's clinical record physician's orders revealed no order for the supplement Magnesium.
Observation of licensed nurse employee E6 on May 14, 2025 at 10:05 a.m. revealed licensed nurse employee E 6 administering morning medication to resident R1. During this observation a bottle of magnesium gummy vitamins 84 mg were viewed on the resident's table.

Interview with Resident R1 at time of the above observation revealed that they are her vitamins and she takes them twice daily. Interview with licensed nurse employee E6 at time of the above observation confirmed that there was no order for this supplement and this nurse was unaware that resident R1 was consuming this supplement.

28 Pa.Code 211.10(c) Resident Care Policies
28 Pa. Code 211.12(c) Nursing Services

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

Resident R1 Orders were updated to reflect an order for Magnesium gummies.
The facility will complete an audit of current residents' rooms to validate residents have physician orders for their medications. Variances were addressed at the time of the audit and placed on the facility audit tool.
The Licensed Nursing Staff will be educated to ensure physician orders are obtained for residents medications.
NHA/Designee will complete random audits 2x per week for 3 weeks and then monthly for 3 months of residents' clinical records to validate residents have physician orders for their medications. The results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations, including any indication of the need for further audits based on the audit findings.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that drugs ad biologicals are stored in a safe/secure environment in accordance with professional standards for one of one medication room and for one of sixteen residents observed. (Resident R60)

Findings include:

Review of facility policy on "Medication Labeling and Storage" dated February 2023, under section "Policy Statement", The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Under section "Policy Interpretation and Implementation", subsection "Medication Storage" 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Subsection "Medication Labeling" #1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. # 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Review of Resident R60's clinical record revealed that Resident R60 was admitted to the facility on April 30, 2025, with diagnoses of but not limited to Chronic Obstructive Pulmonary Disease (COPD-lung an dairway disease that restict breathing).

Review of Resident R60's physician's orders revealed an order for Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder, breath activated 1 puff inhale orally every 12 hours for COPD Instruct patient to rinse mouth to prevent thrush. -start date-05/01/2025

Observation of Resident R60's environment conducted on May 13, 2025, at 9:26 a.m. during the initial tour of the facility revealed the inhaler Fluticasone with Resident R60's name on it on top of the overbed table.

Interview with Resident R60 conducted at the time of the observation revealed that the nurses gave her the Fluticasone. Further interview revealed that Resident R60 did not remember the name of the nurse who gave her the Fluticasone Inhaler.

Follow-up observation conducted with Director of Nursing Employee E2 on May 13, 2025, at 10:04 am revealed that the Fluticasone inhaler was still on top of Resident R60's overbed table.

Interview with DON (Director of Nnursing) Employee E2 conducted at the time of the observation confirmed that Fluticasone inhaler labelled with Resident R60'd name was on top of Resident R60's overbed table.

Observation of the medication refrigerator located in the medication room conducted on May 14, 2025, at 9:57 a.m. with DON, Employee E2 revealed an open vial of tuberculin purified protein derivative.

Further observation revealed that the open vial of tuberculin purified protein derivative was not dated.

Interview with Employee E2 conducted at the time of the observation confirmed that the vial of tuberculin purified protein derivative was not dated.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

Resident R60's inhaler has been removed from her room and stored appropriately. The open vial of tuberculin purified protein derivative has been discarded appropriately.
The Licensed Nursing Staff will be educated on the appropriate labeling, dating and storage of medications. Variances were addressed at the time of the audit and placed on the facility audit tool.
NHA/designee will conduct an audit of resident rooms and medication room to validate medications are stored appropriately, labeled and dated.
NHA/designee will conduct random audits 2x per week for 3 weeks and then monthly for 3 months of resident rooms and medication room to validate medications are stored appropriately, labeled and dated. The results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations, including any indication of the need for further audits based on the audit findings.

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on review of personnel files, review of facility documentation, and staff interview, it was determined that the facility failed to employ a qualified registered dietitian.

Findings include:

Review of dietitian job description revealed the clinical dietitian assesses the nutritional needs and dietary restrictions of the residents to develop and implement a plan of care to meet nutritional needs and maintain overall quality of life. Job descriptions and responsibilities include to complete assessments, chart reviews, develop an individualized nutrition care plan, nutrition focus physical exams, provide nutrition education counseling and support, review all monthly and weekly weights complete assessment and make modifications to nutrition plan of care as clinically indicated. Further review of the dietitians' responsibilities includes collaborate with inner disciplinary team members, consult with positions, assistant coordination of nutritional care services, monitor food service operations, perform all duties necessary and in accordance with the facility policy, understand and follow CMS guidelines and combines with the Department of health regulations. Requirements needed for the position of registered dietitian includes registered dietitian with the American Dietetic Association maintaining the statuses or requirement of the position.

Review of the regional dietitian job description revealed the responsibilities and duties include to provide facility coverage during the absence of a registered dietitian.

Interview on May 14, 2025, at 10:53 a.m. with registered dietitian employee E5 confirmed that the dietitian has not completed the mandatory dietary LDN licensure exam.

Interview with NHA employee E1 and DON employee E2 on May 15, 2025, confirmed that dietician employee E5 has not completed the LDN licensure exam. Employee E5 has been working under the direct supervision of regional dietician employee E 11.

Review of resident records revealed that there was no indication that licensed dietician reviewed or consulted on any clinical documents.

Review of Resident R1's clinical record of dietary notes, weight loss notation, nutritional assessment and care plan, revealed that resident dietician employee E5 was the only employee who reviewed and documented any notes pertaining to resident significant weight loss. There is no cosignature or indication that employee E 11 reviewed and or advised on the clinical record.

28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 211.6(c) Dietary Services

Plan of Correction - To be completed: 06/13/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

Resident R1 clinical record has been reviewed by a licensed dietitian.
NHA/designee will complete an audit of all current resident clinical records to validate they have been reviewed by a Licensed Dietitian. Variances were addressed at the time of the audit and placed on the facility audit tool.

The NHA will educate the dietician/ Licensed Dietician to ensure residents clinical records are reviewed by the Licensed Dietician.
NHA/designee will conduct random audits 2x per week for 3 weeks and then monthly for 3 months of resident clinical records to validate resident clinical records are being reviewed by a licensed dietitian. The results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations, including any indication of the need for further audits based on the audit findings.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement