Aristacare at East Falls

Inspectors wroteBased on review of clinical record, and staff interview it was determined that the facility failed to notify the resident's representative of a significant change in the resident's condition for one of one resident reviewed (Resident R1). Findings Include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of advanced Amyotrophic Lateral Sclerosis (ALS - a progressive neurological disease that results in severe and irreversible muscle weakness, loss of voluntary movement, and loss of speech and swallowing function), tracheostomy status (a surgically created hole in your trachea that allows for breathing), and dependence on ventilator (machines that act as bellows to move air in and out of the lungs). [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to ensure pressure ulcer interventions were documented as ordered by the physician for one of one resident reviewed (Resident R1). Findings Include:Review of undated facility policy Prevention of Pressure Ulcers revealed residents at risk for pressure ulcers include those who are bed and/or chair-fast. General preventative measures include changing position every one to two hours, or more frequently if needed. [...]

Inspectors wroteBased on observations, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that one out of eleven resident room maintained functional running water necessary for hygiene and provision of care. (room [ROOM NUMBER])

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to ensure one resident was free from significant medication error for one of three residents reviewed (Resident R1). Findings Include:Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of anoxic brain damage (oxygen is cut off from the brain), anxiety (intense, excessive, persistent worry or fear), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Review of Resident R1's hospital record revealed an After Visit Summary dated November 4, 2025. Review of Resident R1's After Visit Summary revealed instructions to stop taking the following medications: [...]

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure safety interventions for falls were in place for two of four residents reviewed for falls (Resident R11, R20).

Inspectors wroteBased on observation, interviews with residents and staff, and review of facility documentation, it was determined that the facility failed to ensure that call bells were functioning properly for 6 of 6 resident rooms. (Rooms-717 (A and B), 723, 720-(A and B), 728-B and 733-B)

Inspectors wroteA review of the clinical record for Resident CL1 indicated an admission date of April 18, 2025, with diagnoses including respiratory failure with hypoxia, chronic obstructive pulmonary disease, tracheostomy, and dependence on renal dialysis. Review of Resident CL1's Minimum Data Set (MDS a periodic assessment of care needs), dated August 25, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The clinical record also indicated that Resident CL1 had a Power of Attorney (POA) document on file, signed on February 17, 2025, granting the POA authority to make financial and insurance decisions on behalf of the resident. [...]

Inspectors wroteBased on interviews with residents and staff and review of clinical records, it was determined the facility failed to provide residents who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene related to incontinence care for four of 14 resident records reviewed (Resident R12, R17, R18, and R19).

Inspectors wroteBased on observation, interviews with staff, review of clinical records revealed the facility failed to ensure a resident at risk for pressure ulcers received care, consistent with professional standards of practice, to prevent pressure ulcers for one of 14 resident records reviewed (Resident R12).

Inspectors wroteBased on observation, interviews with staff and review of resident clinical records, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion related to splinting for one of 14 resident records reviewed (Resident R12).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to provide culturally competent, trauma 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 the resident for one of two residents sampled for post-traumatic stress disorder(PTSD). (Resident R7).

Inspectors wroteA review of the facility policy titled, Isolation-Initiating Transmission-Based Precautions undated, revealed Transmission-Based Precautions will be imitated when there is reason to believe that a resident has communicable infection disease. Transmissions-Base Precautions may include Contact Precautions, Droplet Precaution, or Airborne precautions:A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with a physician's order on the same date for tracheostomy and hemodialysis. The clinical record also included special instructions for enhanced barrier precautions due to open insertion sites related to these treatments. On October 16, 2025, at 9:19 a.m., a tour with the Assistant Director of Nursing and Infection Preventionist, Employee E2, revealed that the facility provides bedside hemodialysis to residents. [...]

Inspectors wroteBased on observations, review of facility documentation, staff and resident interviews, it was determined that the facility failed to provide an ongoing program of activities to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities for three of three residents reviewed. (Residents R14, R18 and R21).

Inspectors wroteBased on a review of clinical records and facility policies, observations and staff interviews, it was determined that the facility failed to timely and consistently provide recommended and/or prescribed treatment and services, consistent with professional standards of practice, to prevent new pressure sore development, promote healing and prevent worsening of existing pressure sores related to turning and repositioning for three of seven residents reviewed. (Resident R52, R47 and R5)

Inspectors wroteBased on the review of facility staffing schedule, clinical records, and interviews with staff, residents and resident representative, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing related to interventions to prevent pressure ulcer and restorative nursing services for four of seven residents reviewed. (Residents R52, R47, R5, and R6)Review of an undated facility policy Prevention of Pressure Ulcers, revealed that Identify risk factors for pressure ulcer development 2. For a person in bed. a. Change position at least every two hours or more frequently if needed. Interview with Resident R14, R18 and R21 during resident council meeting held on July 29, 2025, at 11:00 a.m., stated the facility did not have sufficient staffing. Residents stated call bells often take longer to answer and sometimes it could even take one or two hours. [...]

Inspectors wroteBased on review of personnel files and staff interviews, it was determined that the facility failed to ensure that staff demonstrated competency in skills and techniques necessary to care for residents with a restraint in bed and during medication administration via gastrointestinal tube for four of four nursing staff reviewed. (Employees E4, E14, E17 and E18)

Inspectors wroteBased on observation, review of clinical record, interview with staff, and review of facility policy, it was determined that the facility failed to ensure that medications and biologicals are labelled and stored in a safe and secure manner for medication storage areas in two of two nurses' stations observed. (West and East side nurse stations)

Inspectors wroteBased on observations, clinical record reviews, facility documentation and interviews with staff, it was determined that the facility failed to ensure that a physical restraint was used according to the professional standards of practice for one of two residents reviewed. (Resident R23).

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers to the hospital in writing, for one of three clinical records reviewed. (Resident R56)

Inspectors wroteBased on interview and review of clinical records and facility policies it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one resident related to restorative therapy and range of motion for two of 22 resident records reviewed (Resident R6 and Resident R11).

Inspectors wroteBased on interview with resident's representative, staff interview and review of clinical records, it was determined that the facility failed to provide showers for one of five residents reviewed dependent on staff for activities of daily living. (Resident R49)

Inspectors wroteBased upon observation, interviews with resident and staff, and review of clinical records and facility policy it was determined the facility failed to ensure rehabilitative nursing care was provided to one of 14 resident records reviewed (Resident R6)

Inspectors wroteBased upon interviews, review of clinical records and facility documentation and policy it was determined the facility failed to adequately supervise a resident who left the facility without notice for one of 14 resident records reviewed (Resident R8).

Inspectors wroteBased on observation, staff interview, review of clinical record, review of facility policy and competencies, revealed that the facility did not ensure that checks for proper placement of gastric tubes were conducted before medication administration via gastric tube for one of three residents observed. (Resident R59)

Inspectors wroteBased on observation, review of clinical record, staff interview and review of facility policy, it was determined that the facility did not ensure that residents receive oxygen according to physician's orders for one of two residents reviewed. (Resident R11)

Inspectors wroteBased on the review of facility documentation, review of personnel files and interview with staff, it was determined that the facility failed to complete performance review of every nurse aide at least once every 12 months for five of five employees reviewed. (Employees E18, E19, E20, E21 and E22)

Inspectors wroteBased on clinical record review, and staff interviews it was determined that the facility failed to ensure each resident is provided with the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one resident of 13 resident records reviewed (Resident 46). Findings Include: Review of Minimum data set assessment (MDS-periodic assessment of resident's care needs), dated July 10, 2025, indicated that resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in in determining cognitive impairment) score of 0 that indicated that resident's cognitive status was severely impaired. [...]

Inspectors wroteBased upon review of clinical records, facility's pharmacy reviews, and policy it was determined the facility failed to act upon the irregularities noted by the pharmacist in a timely manner for four of 14 resident records reviewed (Residents R2, R4, R7, R8).

Inspectors wroteBased on observation, interview with staff and review of facility policy, it was determined that the facility failed to maintain an effective infection control program to prevent the development and transmission of communicable diseases for one of one resident observed for tracheostomy care. (Resident R54)

Inspectors wroteBased on the review of facility documentations, interview with resident group, and staff interviews, it was determined that the facility failed to post most recent survey results which include any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility readily accessible to residents, and family members and legal representatives of residents.

Inspectors wroteBased on review of clinical records and interview with staff, it was determined facility did not maintain medical records according to professional standards of practice for one of ten residents reviewed (Resident R3)

Inspectors wroteBased on interviews, and a review of facility policies and documentation, it was determined that the facility was not maintaining an effective pest control program.

Inspectors wroteBased on the review of clinical records, facility policies, review of professional standard of practice, observations, and interview with staff, it was determined the facility failed to provide treatment as ordered by the physician, to prevent pressure ulcers. This failure resulted in Immediate Jeopardy situation for Resident R2, Resident R3 and Resident R8 who developed pressure ulcers. The facility failed to provide treatment and services consistent with professional standards of practice to promote healing and prevent infection of existing pressure ulcers. This failure resulted in actual harm to R1, R2, R3, R4, R5, R6, R7, and R8 whose pressure ulcers worsened and/or deteriorated for eight of nine residents reviewed. (Residents R1, R2, R3, R4, R5, R6, R7, and R8) Findings Include: [...]

Inspectors wroteBased on review of job's descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that the facility provides treatment and services consistent with professional standards of practice, to prevent pressure ulcers which resulted in the development of pressure ulcer/s for Resident R2, R3 and R8. The facility failed to provide treatment and services consistent with professional standards of practice to promote healing and prevent infection which resulted in worsening/deterioration of pressure ulcers for R1, R2, R3, R4, R6, R7, and R8. The failure of not properly preventing, managing, and treating pressure injuries placed the residents at the facility at high risk for harm and resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on clinical record reviews, interviews with staff and hospital staff, reviews of hospital records, electronic communication records and facility policies and procedures, it was determined that the facility failed to permit one of one resident's reviewed to return to the facility after hospitalization. (Resident R10)

Inspectors wroteBased on the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with wounds for one of two employee records reviewed. (Employee E8). Findings Include: Review of clinical records revealed that the facility did not provide treatment and services consistent with professional standards of practice, to prevent pressure ulcers which resulted in the development of pressure ulcer/s for Resident R2, R3 and R8. Review of clinical records also revealed that the facility did not provide treatment and services consistent with professional standards of practice to promote healing and prevent infection which resulted in worsening/deterioration of pressure ulcers for R1, R2, R3, R4, R6, R7, and R8. [...]

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for two of two residents reviewed ((Residents R1, and R2).

Inspectors wroteBased on review of clinical record and review of facility provided documentation, it was determined facility did not ensure to complete a care plan that was comprehensive and individualized for one of five residents reviewed related to anxiety (Resident R1)

Inspectors wroteBased on observation, review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to timely assess, monitor and provide treatment consistent with professional standards to Resident R1's sacral pressure ulcer. This failure resulted in actual harm to Resident R1 who experienced a delay in treatment and healing to a sacral pressure ulcer for one of two residents reviewed for pressure ulcer. (Resident R1)

Inspectors wroteBased on observations, review of facility policies and documents, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to enhanced barrier precautions for three of eight of infection surveillance, water management, infection data reporting and infection committee meetings, as required. (Resident 22, Resident 24 and Resident 19)

Inspectors wroteBased on review of personnel files, facility documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for nine of 13 staff reviewed (Employees E22, E10, E23, E24, E28, E29, E30, E31 and E32).

Inspectors wroteBased on observation and interviews with residents and staff, it was determined that the facility failed to maintain or enhance the dignity and respect related to dining for one of one nursing unit. (Nursing Unit rooms 701-738)

Inspectors wroteBased on observations, review of facility policy, clinical record reviews and interviews with staff, it was determined that the facility failed to develop comprehensive care plans related to substance use disorder, pain management, dialysis access, mental health needs and enteral feeding needs for four of 14 residents reviewed (Residents R203, R7, R28 and R26).

Inspectors wroteBased on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for nutrition, mobility, and skin integrity, for three of 14 residents reviewed (Residents R1, R12 and R39).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to blood pressure medications for one of 14 residents reviewed (Resident R7).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of three residents reviewed (Residents R43, R44, and R150 ).

Inspectors wroteBased on a review of personnel files and interviews with staff, it was determined that the facility failed ensure that nursing staff had specific competencies and skills sets necessary to care for residents' needs for seven of 13 personnel files reviewed (Employees E22, E10, E23, E24, E4, E25 and E26).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility to ensure that the consultant pharmacist medication reviews were completed and that recommendations were reviewed by the physician in a timely manner for three of eight residents reviewed for medication regime reviews (Residents R38, R26, R7).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident was free from unnecessary medications, including the proper use and monitoring of medications, for one of 14 residents reviewed (Resident R45).

Inspectors wroteBased on review of facility policies and documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for two of three of residents reviewed for antibiotics (Residents R38 and R26).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to offer influenza and pneumococcal vaccines for five of five residents reviewed for vaccinations (Residents R43, R38, R2, R44 and R12).

Inspectors wroteBased on review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least 12 hours of continuing education per year as required for three of five nurse aide personnel files reviewed (Employees E28, E31 and E32).

Inspectors wroteBased on interviews with resident and staff, review of facility policy, and staff interview, it was determined that the facility failed to ensure that visitors were able to visit residents at all times for one of one resident reviewed. (Resident R203)

Inspectors wroteBased on observation, clinical record review, and review of facility policy and staff interview, it was determined that the facility did not ensure that the resident's privacy, regarding medical records were protected for one of seven residents observed. (Resident R13)

Inspectors wroteBased on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to obtain consent, assess, monitor and re-evaluate hand mitts for one of two residents reviewed for restraints (Resident R150).

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to complete a thorough investigation to rule out neglect related to a fall incident for one of four residents reviewed (Resident R50). Findings Include: Review of facility policy Abuse revealed the policy is intended to provide guidance on investigating and reporting suspected abuse, neglect, and misappropriation of resident property. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. [...]

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for two of six residents reviewed (Residents R26, and R7).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for two of two residents reviewed related to PASRR assessments (Residents R28 and R7)).

Inspectors wroteBased on observations, clinical records reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care, related to respiratory and enteral feeding needs for one of 14 residents reviewed (Resident R150).

Inspectors wroteBased on review of facility policies, review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that the resident and their representatives were involved in an effective discharge planning process for one of three residents reviewed. (Resident R49)

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide adequate monitoring to prevent complications related to enteral feeding for two of four residents reviewed for tube feedings (Residents R150 and R26).

Inspectors wroteBased on review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents received dialysis services consistent with professional standards of practice related to fluid restrictions and dialysis access for one of one residents reviewed who received dialysis services (Resident R7).

Inspectors wroteBased on review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide routine medications to meet residents' needs for two of 14 residents reviewed (Residents R45 and R22).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed ensure that residents were free from unnecessary psychotropic medications, including the proper use and monitoring of medications, use of as needed medications are limited to 14 days and receiving gradual dose reductions, for two of 14 residents reviewed (Residents R45 and R3).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Resident R7).

Inspectors wroteBased on review of clinical records and interview with residents and staff it was determined that the facility failed to routinely offer evening snacks as desired by two of two oriented residents (R21 and R7).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to offer COVID vaccines for three of five residents reviewed for vaccinations (Residents R43, R38 and R44).

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to accurately post information regarding daily nurse staffing data as required.

Inspectors wroteBased on review of professional literature, facility documentation and interviews with staff, it was determined that the facility failed to conduct a facility-wide assessment, using evidence-based methods, that included staff education and competency requirements as well as active involvement from all required participants, as required.

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide assistance with repositioning for three of three residents who were dependent on assistance with activities of daily living (Residents R1, R2 and R3).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of three residents reviewed (Residents R1, R2 and R3).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident received treatment and care in a timely manner related to high glucose levels and emergent transfer to a hospital. This failure resulted in Immediate Jeopardy to a Resident CL1 who had elevated blood sugar levels and was not emergently transferred to a hospital for one of five residents reviewed (Resident CL1). Findings Include: Review of Resident CL1's clinical record reveled that Resident CL1 was admitted to the facility on [DATE], with diagnosis of Diabetes Mellitus (DM-a chronic condition that affects the way the body processes blood sugar (glucose). Review of Resident CL1's [DATE], physician's order revealed an order for Insulin Lispro Injection Solution 100 UNIT/ML; [...]

Inspectors wroteBased on review of clinical records, review of facility investigation and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation to rule out neglect related to a resident who was assessed with high glucose levels and was not emergently transfer to a hospital for one of one resident reviewed. (Resident CL1).

Inspectors wroteBased on observation, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility resulting in an Immediate Jeopardy situation related to a resident who was assessed with high glucose levels and was not emergently transfer to a hospital for one of one resident reviewed. (Resident CL1)

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not maintain complete documentation related to blood sugar levels obtained for three of six clinical records reviewed. (Resident R1, R2, & R3).

Inspectors wroteBased on observations, clinical record review and interviews with staff, it was determined that the facility failed to ensure that resident assessments accurately reflected residents' status related to restraints for one of two residents reviewed on restraints (Resident R36).

Inspectors wroteBased on observations, clinical record review and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission related to ventilators for two of three residents with ventilators reviewed (Resident R1 and Resident R97).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to adequately monitor the nutritional and hydration status for one of two residents reviewed related to nutrition (Resident R1).

Inspectors wroteBased on observations, review of facility policy and interview with staff, it was determined that the facility failed to ensure that physican orders were followed related to one of seven residents reviewed with a gastrostomy tube. (Resident R31)

Inspectors wroteBased on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for nurse aide staff as required for three of three nurse aide personnel files reviewed (Employees E11, E12 and E13).