Eldercrest Rehabilitation & Healthcare Center

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly restrain hair to prevent the potential for cross contamination in the Main Kitchen.

Inspectors wroteBased on review of facility policy and facility documents, resident council meeting and resident and staff interview it was determined that the facility failed to document, investigate, resolve and protect the residents from reprisal during the investigative process when filing/ identifying concerns/grievances for 11 of 18 residents ( Residents R1, R2, R3, R4, R700, R701, R702, R703, R704, R705 and R706).

Inspectors wroteBased on review of facility policies, grievances, clinical records, and resident and staff interview, it was determined that the facility failed to ensure that residents were free from potential abuse/neglect for five of six residents reviewed (Residents R31, R50, R41, R29 and R??)

Inspectors wroteBased on review of facility policy, grievances, facility documents, clinical record reviews and staff interview, it was determined that the facility failed to initiate a thorough investigation for allegations of abuse/neglect for five of six residents (Residents R31, R50, R41, R29 and R??).

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R35). Review of the facility policy Prevention of Pressure Ulcers, dated 7/31/25, indicated that residents are assessed on admission (within eight hours) for existing pressure ulcer/injury and risk factors. the assessment is repeated weekly and upon any changes in condition. Review of the clinical record indicated that Resident R35 was admitted to the facility on [DATE], with diagnoses which included COVID, diabetes, kidney disease and heart fibrillation. [...]

Inspectors wroteBased on observations, review of facility policy, clinical record review, and a staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails/enabler bars were used to meet residents' needs and the risks associated with bedrail usage for three of six residents (Residents R4, R32, and R42).

Inspectors wroteBased on resident and staff interviews, and facility documents (grievance and staffing) reviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 11 of 18 residents (Residents R700, R701, R702, R703, R704, R705, 706 and 707. R41, R50 and R29). Review of a grievance dated 9/10/25, indicated Residents R41 and R50 had indicated that Nurse Aides on the afternoon shifts on the past Sunday (9/7) and Monday (9/8) did not answer call bells and used loud voice. During an interview on 11/12/25, at 12:10 p.m., the DON stated that she did not investigate the grievance and the facility failed to provide sufficient staffing to provide services to attain or maintain the resident's highest practical well-being. [...]

Inspectors wroteBased on observations, facility policy, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during glucometer usage for three of four residents (Resident R42, R14, and R46), and medication administration for one of six residents (Resident R5). Findings Include:A review of the facility policy Obtaining a Fingerstick Glucose Level reviewed 7/31/25, Steps in the Procedure, Step #3: Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Step #18: Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. A review of the facility policy Administering Medications reviewed 7/31/25, indicated staff follows established facility infection control procedures (e.g. [...]

Inspectors wroteBased on observations and a staff interview, it was determined the facility failed to post a statement that the resident may file a complaint with the state agency and had incomplete information for Adult Protective Services (APS) and the Medicaid Fraud Unit, as required within the building.

Inspectors wroteBased on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building.

Inspectors wroteBased on review of facility policy, clinical record review, review of facility provided documentation and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for two of four residents (Residents R1 and R2).

Inspectors wroteBased on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for two of three residents(Residents R21 and R300).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to investigate and/or report potential neglect for two of three residents (Resident R21 and R300).

Inspectors wroteBased on review of facility employee personnel files, documents and staff interviews it was determined that the facility failed to employ a qualified Director of Dining Services(DDS) to manage the daily operations of the Dietary Department.

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to exercise proper infection control techniques and wear proper Personal Protective Equipment (PPE) during a dressing change to prevent the potential of spread of infection for one of three residents (Resident R143).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain the personal privacy of one of three residents (Resident 143).

Inspectors wroteBased on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide a scheduled medication for one of four residents (Resident R147).

Inspectors wroteBased on review of facility policy, clinical record, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of three residents (Resident R147).

Inspectors wroteBased on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for four of nine residents (Resident R1, R2, R3, and R4).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate misappropriation of resident property for eight of nine residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8)

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of eight residents (Residents R1, R9, R10, R11, and R12). Findings Include: Review of the facility policy, Activities of Daily Living (ADLs), Supporting dated 7/31/24, previously reviewed 12/15/23, indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During an interview on 8/31/24, at 2:15 p.m. Resident R12, when asked if she felt the facility maintained sufficient staff, stated, No, and the evening shift doesn't do their jobs. [...]

Inspectors wroteBased on review of facility policy, clinical records, incident reports, resident and staff interview it was determined that failed to report a misappropriation of resident property for one of two residents (Resident R2).

Inspectors wroteBased on Centers for Disease Control and Prevention (CDC) guidance, Pennsylvania Department of Health (PADOH) guidance, facility policy and documents, review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to document surveillance of residents and staff with GI illness, failed to preclude ill staff from working, failed to educate staff on appropriate precautions related to GI illness, resulting in the actual harm of 26 of 43 residents contracting GI illness (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, and R26), and the actual harm of two residents being hospitalized (Resident R14 and R25).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of changes in a resident's blood glucose (BG) levels for one of two Residents (Resident R1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide medically related social services and complete psycho-social based assessments upon admission for four out of five closed resident records (Closed Resident Record CR1, CR2, CR3 and Closed Resident Record CR4).

Inspectors wroteBased on a review of clinical records and resident and staff interview it was determined that the facility failed to involve the resident in the development of the discharge plan for two out of five closed resident records (Closed Resident Record CR1 and CR4).

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to display written information on applying for Medicare and Medicaid benefits, and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (Hall 1 and Hall 2).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care to possibly prevent hospitalization for one of four residents (Resident R4).

Inspectors wroteBased on review of manufacturer's instructions, clinical record review, observations, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for three of four residents (Resident R102, R19, and R28).

Inspectors wroteBased on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to have one or more individuals serving as the Infection Preventionist, responsible for the facility's infection prevention plan, including Covid-19 transmission-based precautions for two of three residents (Resident R94 and R111) Based on observations, review of clinical records, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. [...]

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees E1 and E2).

Inspectors wroteBased on review of facility policy, resident records, and resident and staff interview it was determined that the facility failed to uphold the privacy and dignity of two of four residents (Residents R7 and R17).

Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of four residents (Resident R110).

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to make certain that out-of-date medical supplies were disposed of in one of one medication rooms.

Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the conditions of a binding arbitration agreement and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, one of four residents (Resident R110).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to facility staff.