Matulaitis Rehabilitation & Skilled Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for two of seven sampled residents (Residents #6 and #88) reviewed for accidents, the facility failed to ensure a gait belt was utilized when assisting the resident to ambulate, resulting in a fall with injury and failed to provide adequate supervision in the bathroom resulting in a fall. The findings include: Resident #6's diagnoses included dementia without behavioral disturbance, mood disturbance, anxiety, and difficulty walking. The fall risk assessment tool dated 1/7/26 identified a score of 10 indicating Resident#6 was at moderate risk for falls. Review of the care plan dated 3/14/26 identified Resident #6 was at risk for decline in functional mobility, functional limitation in self-care and falls related to dementia with interventions that directed staff support provided for safety, assist of 1 for transfers and hand-held ambulation and substantial/maximal assistance with toileting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of the clinical record, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for environmental conditions, the facility failed to maintain a safe environment by failing to ensure exterior fire doors in resident-accessible areas were functional and able to securely close. The findings include:Based on observation, review of the clinical record, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for environmental conditions, the facility failed to maintain a safe environment by failing to ensure exterior fire doors in resident-accessible areas were functional and able to securely close. The findings include:Resident #1 was admitted to the facility in August of 2025 with diagnoses that included repeated falls, insomnia and dementia. Resident #1 had a medical responsible party. The elopement evaluation dated 8/13/25 identified Resident #1 was at risk for elopement and an elopement care plan was initiated.The reportable event dated 12/16/25 at 6:45 AM identified the fan in a resident's bathroom on the A wing caught…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to develop a person-centered care plan with individualized interventions to address the resident's assessed risk for elopement. The findings include: Resident #1 was admitted to the facility in August of 2025 with diagnoses that included repeated falls, insomnia and dementia. Resident #1 had a medical responsible party. The elopement evaluation dated 8/13/25 identified Resident #1 was at risk for elopement and an elopement care plan was initiated.The Resident Care Plan (RCP) dated 8/13/25 identified Resident #1 was at risk for elopement related to dementia as evidenced by a history of wandering while in the community and at the facility. The RCP Identified Resident #1 was previously an elevator repair person and had a history of thinking he had a service call and wanting to leave at night per his daughter. Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to provide adequate supervision and prevent accidents by failing to ensure exterior fire doors in resident-accessible areas remained secured and failing to implement adequate interventions for an ambulatory resident assessed as being at risk for elopement, resulting in the resident exiting the facility unsupervised. The findings include: Resident #1 was admitted to the facility in August of 2025 with diagnoses that included repeated falls, insomnia and dementia. Resident #1 had a medical responsible party. The Elopement evaluation dated 8/13/25 identified Resident #1 was at risk for elopement and an elopement care plan was initiated.The Resident Care Plan (RCP) dated 8/13/25 identified Resident #1 was at risk for elopement related to dementia as evidenced by a history of wandering while in the community and at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and facility document review, the facility did not consistently complete sanitation logs for the sanitizing sink according to facility policy. The findings include: On 12/15/2024 at 10:15 AM a tour of the kitchen was completed with the facility dietary manager and assistant manager. A dietary aide was observed washing a pitcher in a 3-bay sink. There were two large gray baking pans soaking in the sanitizing sink (third bay from the left). The dietary aide indicated that she did not check the level of the sanitizer concentration because the cook checked it in the morning before the dishes were washed. A review of the facility documentation for pot sink and bucket sanitizer verification failed to identify that the sanitizer level was checked prior to the washing and sanitizing of the breakfast dishes. Further review of the pot sink and bucket sanitizer verification logs from 6/1/2024 to 12/15/2024 identified that for the months of June, October, and November 2024, there was no documentation of sanitizer verification for breakfast time.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for skin alterations, the facility failed to review and revise the care plan timely to include surgical incisions present on admission and the identified risk for further skin impairment. The findings include: Resident #1's diagnoses included fusion of the spine, chronic congestive heart failure, history of Urinary Tract Infections (UTI's), functional urinary incontinence, muscle weakness and the need for assistance with personal care. The admission Observation dated 9/23/24 identified that Resident #1 was alert and oriented to person, place, time and situation, displayed weakness to both the right and left lower extremities and was observed with a mid-back surgical incision. A physician's order dated 9/23/24 directed to monitor the surgical incision to Resident #1's back for signs and symptoms of infection every shift. A nurse's note dated 9/23/24 at 7:02 PM identified that Resident #1 was admitted to the facility at 2:30 PM with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Resident #1 and #2) reviewed for altered skin integrity, the facility failed to measure two (2) incisional wounds from admission through discharge , failed to ensure that an external catheter device had a physician's order, and failed to ensure that a pressure ulcer risk scale was completed in accordance with facility policy.The findings include: 1) Resident #1's diagnoses included fusion of the spine, chronic congestive heart failure, history of Urinary Tract Infections (UTI's), functional urinary incontinence, muscle weakness and the need for assistance with personal care. The admission Observation dated 9/23/24 identified that Resident #1 was alert and oriented to person, place, time and situation, displayed weakness to both the right and left lower extremities and was observed with a mid-back surgical incision. The Resident Care Plan (RCP) dated 9/23/24 identified that Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for pressure ulcers, the facility failed failed to place additional interventions timely for a resident identified on admission to have a pressure ulcer, failed to ensure that the pressure ulcers were staged and assessed in accordance with facility policy. The findings include: Resident #2's diagnoses included fracture of the right femur, Parkinson's disease, dementia without behavioral disturbances, a stage 4 pressure ulcer of the sacral region (an ulcer at the base of the spine that is down to the bone), anemia and thrombocytopenia (low platelets in the blood that can cause a person to bleed or bruise easily). The admission Observation dated 8/9/21 identified Resident #2 was alert to person, place, time and situation, required assistance with Activities of Daily Living (ADLs) and was admitted to the facility with a pressure ulcer to the coccyx measuring 1.5 centimeters (cm) by 1 cm (not staged). The clinical record lacked a timely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for incontinence, the facility failed to provide staff education to ensure competent nursing staffing related to an external catheter system. Resident #1's diagnoses included fusion of the spine, chronic congestive heart failure, history of Urinary Tract Infections (UTI's), functional urinary incontinence and the need for assistance with personal care. The admission Observation dated 9/23/24 identified that Resident #1 was alert and oriented to person, place, time and situation, displayed weakness to both the right and left lower extremities and had urinary incontinence with no catheters in place. The Resident Care Plan (RCP) dated 10/01/24 identified that Resident #1 was incontinent of urine with interventions that included approaching resident and providing incontinent care during rounds and as needed, assess if the resident is wet/soiled and assess for any redness or breakdown and notifying the nurse of any changes. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1), reviewed for abuse, the facility failed to ensure the resident with treated with dignity. The findings include: Resident #1's diagnoses included dementia with psychotic disturbances, infection to cystostomy catheter, heart failure, and depression. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition, had no behaviors in the prior seven (7) days, and required extensive assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 10/22/23 identified Resident #1 has a history of exhibiting behavioral symptoms including rejection of care, cursing, spitting, and hitting. Interventions directed to provide diversional activities as needed, repeat yourself in a polite manner as needed and to provide simple cueing as needed. Always approach in a calm and friendly manner. Facility incident report and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility documentation, facility policies and interview, the facility failed to ensure food items were consistently labeled and stored to reflect its age or shelf-life or failed to ensure food items and utensils were distributed on the tray line under sanitary condition. The findings included. 1. Observation on 2/23/22 at 11:01 AM during the initial walk-through of the kitchen with the Dietary Supervisor identified the following food items lacked documentation or labeling of a date to reflect the age or shelf-life of a food item. a. Observation of the large walk-refrigerator identified beverages of water and juice were set up on two separate trays to be distributed for lunch. One tray contained 20 glasses of water and the 2nd tray contained 20 cups of juice. Although each beverage was covered with a lid, documentation was lacking to reflect the date the trays of beverages were prepared. It was further noted that a plastic bag containing a single bagel lacked a date. Although the DS indicated the beverage had been poured earlier in the morning on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility documentation, policy and interviews, the facility failed to ensure the 3rd sink (sanitizing sink) was maintained at an effective sanitization level. The findings include: Observation on 8/5/19 at 9:30 AM during a tour of the kitchen with the Dietary Supervisor identified a test of the water in the 3rd sink (sanitizing sink), completed by the Dietary Supervisor, lacked any sanitizer. The Dietary Supervisor indicated that the water in the 3rd sink is used to sanitize bigger pots, pans, utensils and to clean counters and other kitchen areas and prep surfaces via spray bottles. The process for adding the sanitizing solution to the sink was observed posted next to the concentrated sanitizer container located above the sink in the facility kitchen. Directions included to maintain a level of 150 ppm to 400 ppm as an effective sanitizing range. Interview on 8/9/19 at 12:00 PM with the Dietary Supervisor identified that the water in the 3rd sink is changed every 2 hours or so, or after use, and if it gets dirty. Additionally, the Dietary Supervisor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation and staff interviews for 1 of 3 residents (Resident #83) reviewed for pressure ulcers, the facility failed to implement interventions consistent with current standards of practice to prevent the development of a pressure ulcer. The findings include: Resident #83 was admitted on [DATE] with diagnosis that included Alzheimer's disease, and dementia with behavioral disturbance. A weight record dated 4/5/19 identified Resident #83 weighed 152.8 lbs. The admission skin assessment dated [DATE] identified Resident #83 had intact skin without alterations. A physician's order dated 4/5/19 directed to conduct a skin check weekly on bath days. A pressure ulcer risk assessment dated [DATE] identified Resident #14 was at moderate risk for the development of pressure ulcers. The care plan dated 4/6/19 identified Resident #83 was at risk for pressure ulcer development related to dementia, weakness, and incontinence. Interventions included to provide a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, policy and interviews for 1 of 3 residents (Resident #83) reviewed for nutrition, the facility failed to monitor, and implement and/or modify interventions according to facility policy and current nutritional standards of practice to prevent continued weight loss and maintain acceptable parameters of nutritional status. The findings include: Hospital documentation dated 3/31/19 identified Resident #83's albumin was low at 2.3g/dl (Normal range is 3.5-5.0 g/dl). Hospital documentation dated 4/5/19 identified Resident #83's albumin remained low at 3.0g/dl. Resident #83 was admitted on [DATE] with diagnosis that included Alzheimer's disease, and dementia with behavioral disturbance. A weight record dated 4/5/19 identified Resident #83 weighed 152.8 lbs. A physician progress note dated 4/7/19 identified Resident #83 was well developed and well nourished. The care plan dated 4/8/19 identified Resident #83 was at nutritional risk and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.