F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and interview with staff, it was determined that the facility did not develop a
comprehensive care plan related to hospice care for one of 15 records reviewed (Resident R40).
Findings include:
Review of clinical documentation for Resident R40 revealed that she was admitted to the facility on [DATE],
and had diagnoses of dementia, chronic kidney disease, anemia, heart failure, hypertension (high blood
pressure), and polyneuropathy (damage to multiple peripheral nerves).
Review of physician orders for Resident R40 revealed an order for Hospice consult evaluate and treat as
indicated entered on [DATE].
Review of notes for the resident revealed a note dated [DATE], which stated Hospice nurse for evaluation
and resident was signed out as of today, indicating that the resident was admitted to hospice services on
that date. Continued review revealed that the resident had died in the facility on [DATE].
Review of the resident's care plan revealed that no care plan had been developed for hospice services
between her admittance to the service on [DATE], and her death.
Interview with Employee E2, the Director of Nursing, on [DATE], at 2:30 p.m. confirmed that no care plan
had been developed by the facility related to hospice care for Resident R40.
28 Pa. Code 211.10(b) Resident care policies
28 Pa. Code (d)(1) Nursing services
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
Page 1 of 2
Event ID:
395121
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395121
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Simpson House Inc
2101 Belmont Avenue
Philadelphia, PA 19131
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on a review of facility documentation and interviews with staff, it was determined that the facility
failed to complete inservice education based on the outcome of an annual performance review for one of
three nurse aides reviewed. (Employee E10)
Residents Affected - Few
Findings Include:
Review of facility documentation, titled, Standard Job Requirements dated December 13, 2023 revealed
four sections of rating; Exceeds Expectations, Meets Expectations, Needs Improvement, and
Unsatisfactory. Further review of the facility documentation revealed Employee E10 received a score of
Needs Improvement for Maintains confidentiality of all information including resident, employee, operations
data and health information. Under the comments section of this document that was a written comment
stating, Please be mindful of discussing nursing concerns in front of residents and family members.
Appropriate conversation in common areas.
Review of inservices for the year of 2023 and 2024 for Nurse aide Employee E10 revealed that the
employee was found to need improvement in the area confidentiality during performance evaluation.
Continue review of inservices revealed there was no documention of any re-training that occurred for nurse
aide, Employee E10 regarding confidentiality after the performance evaluation.
Interview on July 3, 2024 at 12:12 p.m. revealed the nurse aide, Employee E10 had no documented
re-education of confidentiality after the performance evaluation was completed on December 13, 2023.
28 Pa. Code 201.19 (2) Personnel policies and procedures
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395121
If continuation sheet
Page 2 of 2
