Pennsylvania Department of Health
DELAWARE VALLEY SKILLED NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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DELAWARE VALLEY SKILLED NURSING & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Complaint Survey completed on May 1, 2025, it was determined that Delaware Valley Skilled Nursing and rehab 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:

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

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.

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

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

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

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

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

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

Observations:

Based on a review of clinical records, facility policy, controlled drug shift count records, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed intravenous (IV) antibiotic for one of 16 sampled residents (Resident 34), and maintain accurate controlled drug shift count documentation on one of two medication carts reviewed, thereby failing to promote accountability and medication safety.

Finding included:

A review of a facility policy entitled "Medication Availability" last reviewed by the facility May 2024, indicated a procedure if a medication is not available the facility's procedure required staff to check the Cubex (is an automated medication dispensing machine system used for healthcare management that helps deter delayed medication administration and improve inventory management for healthcare facilities). If the prescribed medication was not available, staff were to contact the pharmacy for delivery status and request STAT (immediate) delivery and place a call into the satellite pharmacy (decentralized pharmacy program) and if the medication is unavailable notify the physician and obtain an order to hold until available or alternative medication is ordered, notify the RR (resident representative), and document outcomes in the nurses' notes.

A clinical record review revealed Resident 34 was readmitted from the hospital to the facility on March 19, 2025, at approximately 2:29 PM, with diagnosis that included, sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) and UTI (urinary tract infection is a general term for infectious diseases in which bacteria enter the urethra, the passage through which urine passes, and propagate inside the body).

Additionally, the resident returned to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart) for medication administration.

A physician's order dated March 19, 2025, directed administration of Meropenem (antibiotic)1 gram IV via PICC line every 12 hours for five days.

A review of nurses' administration note dated March 19, 2025, at 9:28 PM, revealed that Meropenem was not available for administration to the resident.

Further review of a nurses' administration note dated March 24, 2025, at 10:09 PM, revealed that Meropenem was not on unit for administration.

Review of the Medication Administration Record (MAR) for March 2025 revealed missed doses of Meropenem on March 19, 2025, at 9:00 PM, and again on March 24, 2025, at 9:00 PM. Nursing notes documented that the medication was not available on both dates. The clinical record lacked documentation that the physician or resident representative was notified of the missed doses. As a result, the resident did not receive the full course of the prescribed antibiotic therapy.

During an interview with the Nursing Home Administrator (NHA) on May 1, 2025, at 10:30 AM, the NHA acknowledged the facility could not provide documentation confirming that the missed antibiotic doses were administered or that the physician had been notified. The NHA further confirmed the facility had backup pharmacy resources in place that should have been contacted to prevent a missed dose.

A review of the facility policy titled "Controlled Narcotic Sign-off Sheet," last reviewed in May 2024, indicated that Schedule II medications were to be counted and verified at each shift change by both oncoming and outgoing nurses, with signatures required on the shift count sheet to verify accuracy and completion.

A review of the controlled medication shift change log for the 100-unit medication cart revealed missing signatures as follows:
April 25, 2025: Third shift outgoing nurse failed to sign indicating the count was completed and accurate.
April 26, 2025: Day shift oncoming nurse and outgoing nurse both failed to sign indicating the count was completed and accurate.

An interview with Employee 1 Licensed Practical Nurse (LPN) on April 30,2025 at 8:35 AM confirmed the narcotic sheet was not signed off by the off going and oncoming nurses on the above dates.

During an interview with Employee #1, Licensed Practical Nurse (LPN), on April 30, 2025, at 8:35 AM, it was confirmed that the shift count sheet had not been signed by the responsible nurses on the noted dates. In a separate interview conducted with the NHA on April 30, 2025, at 11:45 AM, the NHA confirmed that the facility failed to demonstrate consistent adherence to procedures for verifying and documenting controlled substance counts.

28 Pa. Code 211.9 (f)(2) Pharmacy services

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

28 Pa Code 211.5(f)(x) Clinical records

Plan of Correction - To be completed: 05/09/2025

1. Resident 34 remains stable in facility and Physician will be notified of missed antibiotic. Unable to retroactively correct accurate controlled drug count documentation.

2. Director of Nursing or Designee will complete an audit of all residents to ensure all residents have medication available for administration and if unavailable; medication unavailability procedure followed to include Physician notification. Director of Nursing or designee will complete an audit of all Controlled Narcotic Sign Off Sheets have documentation as required.

3. Director of Nursing or Designee will complete education with Nursing staff on Unavailable Medication Procedure and Controlled Narcotic Sign off Sheet Policy. A review of the existing Medication Availability Procedure will be completed to ensure adequacy and effectiveness of policy. A review of medications in back up cubex will be completed to determine any additional medications needing to be added to the emergency supply.

4. Director of Nursing or designee will complete a random audit of residents daily times 5 days, weekly times 4 weeks and monthly for 2 months to ensure Physician is notified of unavailable medication and back up pharmacy contacted as needed. Director of Nursing or designee will complete a random audit of residents daily times 5 days, weekly times 4 weeks and monthly for 2 months to ensure Controlled Narcotic Sign Off Sheets have documentation as required. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. Committee will determine the need for further audit and/or recommendations.

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

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.

§483.21(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 clinical record review, staff interview, and facility documentation, it was determined the facility failed to develop a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, mental, and psychosocial needs for one of 25 sampled residents (Resident 37), who expressed suicidal ideations.

Findings include:

A review of the clinical record revealed that Resident 37 was admitted to the facility on October 8, 2024, with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily functioning).

A progress note dated April 2, 2025, at 11:45 a.m., documented that the resident expressed suicidal ideation, stating to a staff member that she wanted to kill herself. Following this, the resident was evaluated by the facility's social services department and placed on every 15-minute checks.

However, a review of the resident's comprehensive care plan, in effect as of the survey ending May 1, 2025, revealed no evidence that the facility updated the plan of care to reflect the resident's expressed suicidal ideations or implemented new interventions to address the risk of self-harm. The care plan did not include the resident's psychosocial need related to mental health risk or outline strategies to monitor, support, and ensure the resident's safety.

In an interview conducted on May 1, 2025, at 11:00 a.m., the Nursing Home Administrator confirmed the facility had not developed or updated a person-centered care plan to address the resident's suicidal ideation.

28 Pa. Code 211.11(d) Resident care plan.

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

Plan of Correction - To be completed: 05/20/2025

F 656 Develop/Implement Comprehensive Care Plan

1.Resident 37 care plan will be updated to reflect the residents expressed suicidal ideations, implementation of new intervention to address. Resident 37 care plan will be updated to include psychosocial need related to mental health risk, outline strategies to monitor, support and ensure safety.

2. Social Services Director or designee will complete an audit of all residents to ensure resident care-plan includes psychosocial needs related to mental health risk, outline strategies to monitor, support and ensure safety.

3. Nursing Home Administrator will complete education with Social Services Director to ensure all residents with an identified psychosocial need related to mental health risk as identified through monitoring 24 hour report and nursing to social services communication will have a care-plan to outline strategies to monitor, support and ensure safety. Director of Nursing or Designee will educate the Nursing Department to ensure a note is written in resident chart related to any change in residents mood, mental health status or behavior.

4. Nursing Home Administrator or designee will complete a random audit of residents daily times 5 days, weekly times 4 weeks and monthly for 2 months to ensure Social Services Director completes a care-plan to include psychosocial need related to mental health risk, outline strategies to monitor, support and ensure safety as identified through 24 hour report and behavior tracking. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. Committee will determine the need for further audit and/or recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to review and revise the comprehensive care plan to reflect a significant change in condition related to weight loss for one of 16 residents sampled (Resident 2).

Findings include:

A review of the clinical record revealed that Resident 2 was admitted to the facility on August 9, 2024, with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily functioning).

A review of the resident's documented weights revealed the following:
On November 4, 2024, Resident 2 weighed 203.3 pounds.
On December 4, 2024, the resident weighed 189.5 pounds, which represented a 6.8% loss of body weight in 30 days.

A nutrition progress note dated December 6, 2024, indicated the registered dietitian (RD) assessed Resident 2 due to the identified weight loss and continued to recommend interventions. However, the resident's current care plan, which was originally developed on August 11, 2024, identified the resident as being at nutritional risk related to dementia and a mechanically altered diet, with interventions in place at that time.

Upon review of the care plan during the survey conducted April 28 through May 1, 2025, there was no documented evidence the care plan had been reviewed or revised to reflect the resident's significant weight loss identified in December 2024. There were no new interventions added or existing interventions updated to reflect the change in nutritional status or to address the resident's ongoing weight trends.

An interview was conducted with the Nursing Home Administrator on May 1, 2025, at 2:30 PM. The Administrator confirmed the facility failed to update Resident 2's care plan following the significant weight loss noted in December 2024 and acknowledged the resident's plan of care should have been reviewed and revised to reflect the change in condition and the resident's current needs.

28 Pa. Code 211.11(d) Resident care plan.

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

Plan of Correction - To be completed: 05/20/2025

1. Resident 2 care-plan was updated to reflect the significant weight-loss with interventions to address nutritional status.

2. Dietician or designee will complete an audit of all residents to ensure residents with significant weight loss have an updated care-plan with interventions to address nutritional status.

3. Nursing Home Administrator or designee will complete education with Dietician to ensure residents with significant weight loss have an updated care-plan with interventions to address nutritional status timely. Nursing to Dietary referral to be completed for residents with weight loss.

4. Nursing Home Administrator or Designee will complete an audit of residents identified with significant weight change daily times 5 days, weekly times 4 weeks and monthly times 2 months to ensure Dietician updates care plan related to significant weight loss with interventions to address nutritional status. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. Committee will determine the need for further audit and/or recommendations.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 6 shifts out of 51 reviewed.
Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census.

January 1, 2025- 3.57 nurse aides on the night shift versus the required 3.80 for a census of 57.

March 26, 2025- 3.33 nurse aides on the night shift versus the required 4.33 for a census of 65.

March 27, 2025- 4.20 nurse aides on the night shift versus the required 4.40 for a census of 66.

March 28, 2025- 3.90 nurse aides on the night shift versus the required 4.47 for a census of 67.

March 29, 2025- 3.60 nurse aides on the night shift versus the required 4.40 for a census of 66.

March 30, 2025- 3.70 nurse aides on the night shift versus the required 4.40 for a census of 66.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on May 1, 2025, at approximately 1:00PM, confirmed the facility had not met the required nurse aide and licensed practicing nurse to resident ratios on the above dates.

Plan of Correction - To be completed: 05/20/2025

1. Unable to retroactively correct meeting nurses aid ratios on January 1, March 26th, March 27th, March 28th, March 29th, March 30th.

2. Nursing Home Administrator or designee will complete an audit for the past 3 days to determine if the facility staffing ratio requirements were met.

3. Facility Consultant or designee will provide education to Nursing Home Administrator or designee to ensure staffing ratios are maintained as per regulation.

4. Nursing Home Administrator or designee will complete a random audit daily times 5 days, weekly times 4 weeks and monthly for 2 months to ensure staffing ratios are met. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. Committee will determine the need for further audit and/or recommendations.

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