Inglis House

Inspectors wroteBased on review of facility policy, review of facility documentation, observations, and interviews with staff and residents it was determined that the facility failed to provide timely assistance with activities of daily living care for dependent residents for 3 of 10 residents reviewed (Resident R2, R9 and R6). Findings Include:Review of facility grievance records from January 2026 through June 2026 revealed ongoing concerns regarding staff responsiveness and timeliness of care. The monthly grievance logs documented repeated complaints involving delayed incontinence care, residents not awakened for care services, and delays in responding to resident requests. [...]

Inspectors wroteBased on review of personnel files and staff interviews it was determined that the facility failed to ensure licensed, direct-care staff maintained current certification in Cardiopulmonary Resuscitation (CPR) for one of four personnel files reviewed (Employee E15). Findings Include: Review of personnel file for Respiratory Therapist, Employee E15, revealed the employee had an expired CPR certification (Cardiopulmonary Resuscitation -lifesaving procedure that maintains blood flow and oxygen to the brain and heart when the heart or breathing stops). Interview on [DATE], with Respiratory Therapist, Employee E15, confirmed CPR training was not renewed. Interview on [DATE], with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed Respiratory Therapist, Employee E15, had an expired CPR certification. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to administer medications in accordance with physician orders for one of ten residents reviewed (Resident R4). Findings Include:Review of facility policy titled General Medication Procedures, revised September 3, 2025, revealed the purpose of the policy is to ensure residents receive medications in a timely manner, maintain continuity of prescribed therapeutic regimens, ensure prompt administration of initial medication doses, and provide medications in accordance with physician orders. The policy establishes that nursing staff are responsible for ensuring medications are available, accurately prepared, administered timely, and monitored to ensure residents receive prescribed medications without unnecessary delay or interruption. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of ten residents reviewed (Resident R1). Findings Include:Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], has a BIMS (brief interview for mental status) score of 15 (indicating intact cognitive function), and requires set-up assistance for eating. [...]

Inspectors wroteBased on staff interviews and observations, it was determined that the facility failed to ensure that resident call bells were within reach of them for 4 out of 5 residents observed (Resident R3, R4, R5, and R6).

Inspectors wroteBased on staff interviews, review of clinical records, and the review of facility documentation, it was determined that the facility failed to ensure that a resident received incontinence care in a timely manner for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to ensure the use of outside resources for one of 36 residents reviewed (Resident R135). Findings Include: Review of Resident R135's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 29, 2026, revealed the resident was cognitively intact and had diagnosis of obstructive sleep apnea (sleep disorder where the airway repeatedly becomes blocked during sleep, causing pauses in breathing and disrupted sleep). [...]

Inspectors wroteBased on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that pain management was provided consistent with professional standards of practice, for one of 6 sampled residents (Resident R1).

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to timely notify the physician of a new skin impairment for one of three residents reviewed (Resident R1). Findings Include:Review of facility policy Notification of Change in Resident Status/Condition revised October 15, 2016, revealed the nurse will contact the physician to report nursing assessment/observations involving incidents, accidents, and significant changes in physical status. The nurse will obtain new orders as warranted from the physician, and these orders will be documented in the electronic medical record. [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to conduct a complete and thorough investigation related to a pressure ulcer for one of three residents reviewed (Resident R1). Findings Include:Review of facility policy Abuse, Neglect and Exploitation revised August 19, 2025, revealed the facility will thoroughly investigate all reports of suspected or alleged abuse, and neglect; as well as all injuries of unknown origin to rule out potential abuse. Documentation pertinent to the investigation shall consist of written signed statements from the resident and witnesses. Interviews should be inclusive of employees (on all shifts) having contact with the resident during the period of the alleged incident. [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide pressure ulcer treatment consistent with standards of professional practice for one of three residents reviewed (Resident R1). Findings Include:Review of facility policy Skin Integrity: Wound Monitoring revised September 22, 2016, revealed when a new wound is identified the licensed nurse will measure the wound and document findings in the electronic medical record (EMR), and notify the Registered Nurse, and Physician. The physician's order for wound care treatments should include cleansing agent, frequency, and dressings as indicated. [...]

Inspectors wroteBased on observations, review of clinical record, facility policies, facility documentation, and interviews with staff, it was determined the facility failed to adequately supervise one of five residents reviewed (Resident R1). This failure resulted in Resident R1 wandering in the hallways of the facility on an electric wheelchair, and accessing the fire stairway entrance door, falling down a flight of stairs while strapped to the wheelchair. Resident R1 was missing for a period of approximately four hours after the fall. Resident R1 required transfer to the hospital and diagnosed with rib fractures, a fracture of the right clavicle, a subdural hematoma and closed dislocation of left finger and five stiches to the right top of the head. This deficiency was identified as Immediate Jeopardy Past Noncompliance. (Resident R1)

Inspectors wroteBased on review of clinical record, review of job's descriptions and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that adequate supervision was provided to on one of one resident reviewed (Resident R1) at risk for elopement. This failure resulted in Resident R1 wandering in the hallways of the facility on an electric wheelchair, and accessing the fire stairway entrance door, falling down a flight of stairs while strapped to the wheelchair. Resident R1 required transfer to the hospital and diagnosed with rib fractures, a fracture of the right clavicle, a subdural hematoma and closed dislocation of left finger and five stiches to the right top of the head. This deficiency was identified as Immediate Jeopardy Past Noncompliance. (Resident R1)

Inspectors wroteBased on the review of facility documentation, clinical records, hospital records, and interviews with resident and staff, it was determined the facility failed to provide appropriate staff supervision for Resident R1. This failure resulted in actual harm to Resident R1 who was found with a vertical laceration beginning at the midline of the forehead extending towards the scalp for one of 7 residents reviewed. (Resident R1)

Inspectors wroteBased on review of clinical record, faciltiy documentation, facility policy, and staff interviews it was determined the facility failed to ensure there was a sufficient number of nursing staff available to provide care for one of seven residents reviewed. (Resident R1)

Inspectors wroteBased on a review of facility policy, clinical records, staff training records, information submitted by the facility, and staff and resident interviews, it was determined the facility failed to ensure the resident environment remained free of accident hazards resulting in actual harm to Resident R127 who sustained a second degree burn on the left knee when an employee's personal hot beverage spilled on the resident for one of 35 residents reviewed (Resident R127). This deficiency is cited as past non-compliance.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and an interview with staff, it was determined that the facility failed to properly dispose of facility garbage.

Inspectors wroteBased on review of facility protocol, observations, and staff interviews, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for resident's on enhanced barrier precautions during wound care and medication administration as ordered by the physician for four of 35 resident reviewed. (Resident R18, R78, R93, R112) Findings Include: Review of an undated facility policy Enhanced Barrier Precaution Review of physician orders for Resident R18 dated February 25, 2025, revealed that the resident was ordered for enhanced barrier precaution ESBL (Extended-Spectrum Beta-Lactamase, an enzyme produced by some bacteria that makes them resistant to certain antibiotics, including penicillin and cephalosporins) in the urine. Observation of the Resident R18's wound care on March 19. 2025, at 11:30 a.m. [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of two staff observed (Employee E6 and failed to ensure residents' privacy was maintained before entering rooms for two of 35 residents reviewed (Residents R9 and R62).

Inspectors wroteBased on observation, clinical record review, and interviews with residents and staff, it was determined that the facility did not ensure timely revision of the comprehensive care plan related to wounds for one of 35 records reviewed (Resident R93).

Inspectors wroteBased on a review of clinical records and interviews with staff, it was determined that the facility failed to meet professional standards related to medication administration for one of five residents reviewed (Resident R167).

Inspectors wroteBased on review of clinical records, facility policy, observations, and staff interviews, it was determined that the facility failed to provide appropriate tracheostomy care for one of two residents reviewed receiving respiratory services. (Resident R43)

Inspectors wroteBased on review of clinical records, staff and resident interviews, 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 four of four residents sampled for post-traumatic stress disorder(PTSD) care. (Resident R158, R113, R102, and R130).

Inspectors wroteBased on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for five of five nurse aides' personnel files reviewed related to performance reviews as required (Employees E13, E14, E15, E16 and E17).

Inspectors wroteBased on review of facility records and interviews with staff, it was determined that the facility did not ensure that the record for reconciliation of controlled drugs was complete related to missing signatures on the Narcotic Count Sheet for one of five medication carts reviewed (3 North cart A).

Inspectors wroteBased on observation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that medications were stored and labeled properly related to labeling of open liquid medications, disposition of medication for discharge residents, and securing the cart lock when the nurse was not in sight for three of five medication carts reviewed (1 North cart A, 1 South cart B, and 3 North cart A).

Inspectors wroteBased on review of clinical record review and staff interviews, it was determined that the facility failed to follow physician orders for one of seven residents (Resident R2).

Inspectors wroteBased on staff and resident interviews and review of facility documentation, it was determined that the facility failed to ensure that a resident's grievance was filed and investigated for or 1 out of 3 residents reviewed (Resident R2).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident with a diagnosis of heart failure for 1 out of 3 resident's reviewed (Resident R1).

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to ensure that daily weights were obtained as ordered by the physician for a resident with a diagnosis of health failure, for 1 out of 3 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews and review of clinical records, it was determined that the facility failed to ensure that physician monitoring a resident with a diagnosis of heart failure for 1 out of 3 residents reviewed (Resident R1).

Inspectors wroteBased on review of clinical records, review of facility policies, review of facility investigation, review of facility policies and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of 35 residents reviewed (Resident R147).

Inspectors wroteBased on review of facility policy, clinical record review and interview with staff, it was determined that the facility did not ensure that a resident was free from misappropriation of property for one of 35 records reviewed (Resident R128).

Inspectors wroteBased on review of clinical records, observations, facility provided documentation and review of documentation from the Center of Disease and Control Prevention (CDC), it was determined that the facility did not ensure to develop and implement a care plan that includes measurable objectives, interventions and time frames for how staff will meet the residents' needs related to catheter care and enhanced barrier precautions for two of 35 residents reviewed (Residents R84 and R77)

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that a resident was free from an excessive dose of pain medication for one of 35 records reviewed (Resident R165).

Inspectors wroteBased on reviews of dietary policies and procedures, interviews with residents and staff and observations of the food and nutrition services, it was determined that foods were not prepared and served by methods to conserve nutritive value, flavor and appearance. ( Residents R1, R2 and R3)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility did not ensure that physician's orders were followed or clarified regarding the administration of two medications for one of eleven residents reviewed (Resident R3). Findings Include: Review of the medical record revealed that Resident R3 was admitted on [DATE], with diagnosis including, but not limited to neuromuscular bladder dysfunction (also known as Neurogenic Bladder, is when a person lacks bladder control due to brain, spinal cord or nerve problems) and insomnia (trouble falling and/or staying asleep). Further review of the clinical record for Resident R3 revealed an January 23, 2023, physician order for Lithostat Tablet 250 mg (Acetohydroxamic Acid), give 250 mg by mouth three times a day for Neurogenic bladder. [...]

Inspectors wroteBased on review of clinical record, review of facility documents and interview with staff, it was determined that the facility failed to ensure that the physician's order were followed. For one of two residents reviewed.

Inspectors wroteBased on observations, review, facility policy and interviews with staff, it was determined that the facility did not ensure that food was distributed at appropriate temperatures and one of two dining rooms observed.

Inspectors wroteBased on review of facility's policies, review of clinical records and staff interviews, it was determined that the facility failed to ensure that an alleged violations involving resident neglect was reported to the State Survey Agency (Department of Health) for one of three residents reviewed (Resident R1).

Inspectors wroteBased on observation, review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to ensure that feeding formulas were labelled according to professional standards for five of five residents with tube feeding observed (Residents R1, R2, R3, R4 and R5).

Inspectors wroteBased on interviews with staff and residents, and the review of the clinical record and facility documentation, it was determined that the facility failed to ensure that 1 out of 3 residents reviewed were properly assessed to self-administer a supplement and medications (Resident R1).

Inspectors wroteBased on review of facility policy, review of resident clinical records, observation, and staff interview, it was determined that the facility failed to uphold the privacy and dignity of two of 4 residents utilizing catheter care (Residents R107, R113).

Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for diabetic management care needs and post traumatic stress disorder (PTSD) for two of 34 residents reviewed (Resident R24 and R16).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least twelve hours of continuing education per year as required for one of six nurse aides reviewed (Employee E10).