Naamans Creek Country Manor

In the surveyor’s words

From the most serious findings on record at Naamans Creek Country Manor, in the surveyor’s own words.

• Actual harm, isolatedF684May 9, 2023

  Based on a review of the facility's policy, clinical records, and staff interviews, it was determined that the facility failed to follow physician's order to monitor the resident's vital signs and to timely notify the physician of an abnormal blood pressure reading resulting in actual harm of hospitalization for one of three residents reviewed (Resident 1). Findings include: Review of the facility's policy titled Vital Signs, Frequency, May 2022, revealed that upon admission or readmission of a resident to the facility, vital signs will be obtained every shift for 72 hours to establish baseline vital signs. […]

• Actual harm, isolatedF686Jun 28, 2021

  Based on observation, review of the facility policy and clinical records, and staff interview, it was determined that the facility failed to timely assess and provide wound treatment to a sacral wound resulting in actual harm of advanced stage pressure ulcer from a Stage two (an ulcer involving loss of the top layers of the skin) to a Stage three (ulcer involving the full thickness of skin loss, exposing tissue) to one of 19 residents reviewed (Resident 46). Findings include: A review of the facility's policy entitled, Skin Integrity Management, with a revision date of December 20, 2019, revealed that a complete comprehensive evaluation of the patient upon admission/re-admission to the center is a practice standard. […]

• No harm, potential for more than minimal, widespreadF812May 2, 2025

  Based on observations, review of facility policies, and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety for two of two nursing units (First Floor and Second Floor nursing units). Findings include: Review of the facility policy, Dry Food Storage dated [DATE], revealed, dry food storage is necessary for foods that do not require refrigeration or freezing and requires proper guidelines. All food items must be dated, labeled and sealed. Rotate products to ensure that the oldest inventory is used first. Observation on [DATE], at 9:45 a.m. of the second-floor kitchen dry food storage area revealed expired used by dates for multiple loaves of bread and packages of buns. […]

• No harm, potential for more than minimal, patternF812Jun 26, 2026

  Based upon observation and interview, it was determined that the facility failed to ensure appropriate storage, labeling, and dating was completed for pre-prepared food items in the refrigerator. Observation of the facility refrigerator located in the kitchen on June 24, 2026, at 12:48 p.m. revealed a clear plastic container filled with prepared chicken salad sandwiches. The container was covered with a loose sheet of parchment paper, held in place with a plastic bucket of chicken salad. Interview with the kitchen manager on June 24, 2026, at 12:50 p.m. confirmed that the prepared sandwiches were not properly labeled, dated, or covered. The facility failed to ensure that food was stored properly, labeled, and dated according to professional standards. 28 Pa. Code 201.18(b)(1)

• No harm, potential for more than minimal, patternF684May 2, 2025

  Based on a review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to ensure physician's orders were followed for three of the 18 residents reviewed (Residents 13, 14, and 66). Findings include: A review of the facility's policy titled Weighing of Residents, undated revealed that residents requiring daily weights due to clinical conditions warranting strict monitoring will be weighed in the same procedures as stated above. Documentation of the daily weight will be recorded in the electronic medical record (EMR). […]