Aristacare At East Falls
Inspection Findings
F-Tag F0760
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 Resident R1).Findings Include:Review of Resident Resident R1's clinical record revealed the resident was admitted to the facility on [DATE REDACTED], 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 Resident R1's hospital record revealed an After Visit Summary dated November 4, 2025. Review of Resident Resident R1's After Visit Summary revealed instructions to stop taking the following medications: clonazepam (used to treat seizures and panic disorders), Keppra (seizure treatment), Seroquel (antipsychotic), and Valproic Acid (primarily used to treat seizures)Review of Resident Resident R1's clinical record revealed physician orders dated November 5, 2025, to administer Keppra 1000 milligrams (mg) every 12 hours for seizure, Clonazepam 25 mg two times per day, Seroquel 25 mg two times per day, and Valproate (valproic acid) 15 milliliters (mL) every 8 hours for seizures.Review of Resident Resident R1's medication administration record revealed:Clonazepam was administered twice on November 5, 2025, and Seroquel was administered once on November 5, 2025.Keppra and valproic acid were administered as ordered from November 5, 2025, through November 11, 2025.Review of Resident Resident R1's clinical record revealed a progress note dated November 6, 2025, by the Nurse Practitioner, Employee E3, that revealed [family] at bedside concerned about medications. Further review of the progress note dated November 6, 2025, revealed Resident Resident R1 was noted to be lethargic and was awaiting proper medication list from the hospital.Interview on December 29, 2025, at 2:35 p.m. with Nurse Practitioner, Employee E3, revealed the facility did not have Resident Resident R1's medication discharge list from the hospital when the resident was admitted . Nurse practitioner, Employee E3, indicated he/she adjusted the Clonazepam and Seroquel to be administered only as needed (versus standing orders) after medication concerns were brought to his/her attention by Resident Resident R1's family.Continued interview on December 29, 2025, at 2:35 p.m. with Nurse Practitioner, Employee E3, revealed he/she kept reminding nursing staff to obtain an updated medication list from the hospital.Further interview with Nurse practitioner, Employee E3, revealed that he/she was unaware that the hospital gave instructions to discontinue the Valproic acid and Keppra.28 Pa Code 211.9(a)(1) Pharmacy services28 Pa Code 211.12(d)(5) Nursing services
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
ARISTACARE AT EAST FALLS in PHILADELPHIA, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PHILADELPHIA, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ARISTACARE AT EAST FALLS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.