Pennsylvania Department of Health
MARYWOOD HEIGHTS
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 59 surveys for this facility. Please select a date to view the survey results.

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MARYWOOD HEIGHTS - 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 8, 2025, it was determined that Marywood Heights was not in compliance with the follow requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 06/10/2025

1. Facility is unable to retroactively correct the deficient practice.
2. Director of Nursing or designee will complete a 24 hour lookback of current residents medication order times vs administered times to verify resident medications are given timely.
3. Licensed nursing will be educated on medication time distribution.
4. Director of Nursing or designee will complete a weekly audit times 4 week weeks of random residents to verify that current and new residents have medications given and documented timely.
5. Facility will be in compliance on June 10, 2025

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.

Plan of Correction - To be completed: 06/10/2025

1. Medications found unsecured were properly disposed of.
2. Director of Nursing or designee will complete an audit of current residents medications to verify resident medications in the medication carts are active orders and any discontinued medications are removed and appropriately disposed of.
3. Licensed nursing will be educated on medication storage and destruction.
4. Director of Nursing will complete a random weekly audit times 4 week weeks to verify that current and new residents have medications stored and disposed of properly.
5. Facility will be in compliance on June 10, 2025.

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

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

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

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

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

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

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

Plan of Correction - To be completed: 06/10/2025

1. Facility is unable to retroactively correct the deficient practice of shift to shift sign off.
2. Current and new residents are at risk of this deficient practice. Director of Nursing or designee will complete an audit of narcotic books of current residents to verify that licensed nursing is completing and documenting a shift to shift sign off.
3. Licensed nurses will be educated on narcotic shift to shift sign off documentation.
4. Director of Nursing or designee will complete a random weekly audit times 4 weeks to verify that licensed nursing is completing the narcotic sign off.
5. Facility will be in compliance on June 10, 2025.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by six of six residents attending a resident group meeting (Residents 16, 43, 62, 129, 32, and 71) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.

Findings include:

A review of the facility's "Grievance Policy" last revised in December 2019 indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay". Further stating the grievance official or designee will meet with the resident to formally review the resolution to the grievance.

A review of the Minutes from Resident Council meetings dated March 5, 2025, revealed concerns from residents that call bells were not answered timely. A grievance was filed on March 5, 2025, regarding this concern. Review of this grievance revealed no follow up was completed with the residents who raised this concern during resident council. There was no documented evidence of corrective actions taken to address this issue.

A group meeting conducted on May 7, 2025, at 10:00 a.m. with six residents (Residents 16, 43, 62, 129, 32, and 71) revealed unanimous reports the facility failed to address their complaints regarding the timeliness of call bell response.

The facility was unable to provide documented evidence that efforts had been made to resolve resident complaints concerning call bell timeliness as of the survey ending May 8, 2025, that had been brought up during resident council meeting.

During an interview on May 8, 2025, at 9:10 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the absence of documented actions addressing grievances raised during Resident Council meetings or verbal complaints.

28 Pa. Code 201.18 (e)(1)(4) Management

28 Pa. Code 201.29(a) Resident Rights

Plan of Correction - To be completed: 06/10/2025

1. Facility is not able to retroactively correct the deficiency.
2. Activities Director or designee will complete an audit of alert and oriented residents with a BIMS over 12 to verify if they have any active concerns with timeliness of call bell response.
3. NHA will educate Activities Director and Social Services Director on proper resolution of grievances and follow up to residents concerns.
4. Activities Director or designee will complete a random weekly audit times 4 weeks to verify that call bell response times are within acceptable time frames. NHA will complete a random weekly audit times 4 weeks to verify that any grievances are properly resolved.
5. Facility will be in compliance on June 10, 2025.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Plan of Correction - To be completed: 06/10/2025

1. Facility is unable to retroactively correct the deficient practice. Resident 69's pain regime will be reviewed and updated as needed.
2. Director of Nursing or designee will complete an audit of current residents receiving PRN pain medication, to verify residents are administered PRN Pain medication per the appropriate pain scale, and non pharm interventions were attempted and documented before medication given.
3. Licensed nurses will be educated on providing and documenting non pharm interventions prior to dispensing PRN pain medications, and accurate documentation of pain scales.
4. Director of Nursing or designee will complete a random weekly audit times 4 weeks to verify that current or new residents who received PRN pain medications have the appropriate pain scale documented and that non -pharm interventions were attempted prior to medication administration.
5. Facility will be in compliance on June 10, 2025

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 18 residents sampled (Resident 56).

Findings included:

A review of Resident 56's clinical record revealed the resident was admitted to the facility on June 7, 2024, with diagnoses to include senile degeneration of the brain (a decline in cognitive function associated with aging) and chronic lymphocytic leukemia (a slow growing cancer of the white blood cells).

A nursing progress note dated April 23, 2025, indicated the resident was noted to have yellow discharge from his penis. The physician was notified, and an order was obtained for a Urinalysis with Culture and Sensitivity (UA C&S a laboratory test used to detect and identify bacteria or fungi in urine, A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) to assess for possible infection.

A nursing progress note dated April 24, 2025, at 10:22 AM documented that a urine sample was obtained from the resident, the progress note further revealed the resident's urine appeared concentrated (dark in color, indicating potential infection or dehydration)

A review of a nursing progress notes dated April 25, 2025, at 10:40 AM revealed the resident's urinalysis results were received, and faxed to the physician with no new orders at the time.

A review of a nursing progress notes dated April 25, 2025, at 1:37PM revealed a new order for Ciprofloxacin 500mg by mouth twice daily for 7 days for a diagnosis of a urinary tract infection.

A review of the resident's laboratory report dated April 25, 2025, 10:10AM revealed the urine culture identified Morganella morganii (a rare infection of urinary tract, commonly associated with antibiotic resistance. These enzymes break down certain antibiotics making the bacteria resistant to these medications) with bacterial growth of 50,000- 100,000 CFU/ml. The report further indicated the prescribed antibiotic (Ciprofloxacin) was resistant to the bacteria found in the resident's urine, rendering the treatment ineffective.

A review of Resident 56's Medication Administration Record (MAR) for April 2025 revealed the resident received eight (8) doses of Ciprofloxacin, an unnecessary antibiotic, even though the culture and sensitivity results confirmed the prescribed medication was ineffective.

During an interview with the Director of Nursing (DON) on May 8, 2025, at approximately 1:15 PM, the DON confirmed the administration of Ciprofloxacin was not clinically justified, as the prescribed antibiotic was ineffective against the identified organism. The DON acknowledged the resident received an unnecessary medication, which did not align with evidence-based infection control and antimicrobial stewardship practices.

28 Pa. Code 211.2(d)(3)(5) Medical Director

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

Plan of Correction - To be completed: 06/10/2025

1. Facility is unable to retroactively correct the deficient practice.
2. Infection Control Preventionist RN will complete an audit of current residents on antibiotics to verify that the criteria is met for antibiotic use and that the antibiotic prescribed is appropriate for diagnosis.
3. ICP will be educated on McGeer's criteria and physician notification/education if antibiotic is not indicated as appropriate for diagnosis.
4. ICP will complete a random audit weekly times 4 weeks to verify that current and new residents on antibiotics meet the McGeer's criteria, and physician education is completed if necessary.
5. Facility will be in compliance on June 10, 2025.

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