Aristacare at East Falls

In the surveyor’s words

From the most serious findings on record at Aristacare at East Falls, in the surveyor’s own words.

• Immediate jeopardy, patternF686May 13, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Aug 8, 2024

  Based 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). […]

• Actual harm, isolatedF686Oct 16, 2024

  Based 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) Findings include: Review the facility policy on Pressure Ulcer Treatment revealed that under section Purpose stated that the purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Under section General Guidelines #1. […]

• Actual harm, isolatedF695Apr 15, 2022

  Based on review of clinical records, review of facility policies, review of manufacturer's guidelines and interviews with staff, it was determined that the facility failed to perform a required pre-used test of a ventilator to ensure proper function which resulted in actual harm to Resident R1 whose ventilator did not alarm when the resident became disconnected from the ventilator and in the resident's death for one of three ventilator dependent residents (Resident R1) Findings include: Review of facility policy, Vent Checks dated April 1, 2018, revealed Ventilator monitoring shall be done on an ongoing basis by the RCP (Respiratory Care Practitioner) and nursing . […]

• No harm, potential for more than minimal, widespreadF880Oct 4, 2024

  Based 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) Findings include: Review of facility policy, Infection Prevention and Control Manual dated June 13, 2024, revealed that the Infection Control Committee has the authority to implement effective measures for the detection, surveillance, control and prevention of healthcare associated infections. […]