Slate Belt Health & Rehabilitation Center

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for two residents in one of two dining rooms. (Residents 77, 106)Findings include: Clinical record review revealed that Resident 77 had diagnoses that included Parkinson's disease, dementia, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated January 4, 2026, revealed that the resident had cognitive impairment and required assistance from staff with eating. Review of Resident 77's care plan revealed that the resident was at increased nutrition and hydration risk with an intervention for staff to encourage oral intake and assist with dining. On January 12, 2026, 12:05 p.m. through 12:18 p.m., Nurse Aide (NA) 2 was observed standing to assist Resident 77 to eat lunch, while the resident was seated in the wheelchair. Clinical record review revealed that Resident 106 had diagnoses that included benign neoplasm of the brain, cortical blindness (partial or total loss 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.

Based on facility policy review, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 23 sampled residents. (Residents 7, 12)Findings include: Review of the facility policy entitled, Self-Administration of Medications, last reviewed January 31, 2025, revealed that the facility was to assess and determine whether self-administration of medications was safe and clinically appropriate based on the resident's functionality and health condition. The policy also stated that the facility was to document in the resident's care plan whether the resident or facility staff was responsible for the storage of resident's medications and if the resident had been assessed as being responsible for the storage of his/her medications. The facility was to provide a secure compartment for storage of such medications in the resident's room. Clinical record review revealed that Resident 7 had diagnoses that included arthritis, fracture of the left femur, and muscle…

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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide the physician ordered therapeutic diet for one of 23 sampled residents. (Resident 6)Findings include: Clinical record review revealed that Resident 6 had diagnoses that included heart disease, Parkinson's disease, and gastro-esophageal reflux disease (a chronic digestive disorder where stomach acid frequently flows back into the esophagus). A physician's order dated January 9, 2026, directed staff to provide a clear liquid diet for 48 hours. A dietary progress note dated January 12, 2026, stated that resident was to receive a clear liquid diet for all 3 meals on January 10 and 11, 2026. On January 11, 2026, at 1:00 p.m., the resident was observed eating lunch in his bed. The food items on his tray were mechanical soft vegetables and pureed roast beef. In an interview on January 13, 2026, at 11:10 a.m., the Registered Dietitian confirmed that the resident should have received a clear liquid diet for lunch on Sunday, January 11, 2026. 28 Pa. Code 201.14(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.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and the use of personal protective equipment (PPE) to prevent the spread of infection for one of 23 sampled residents. (Resident 8)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed January 31, 2025, revealed that enhanced barrier precautions were to be used with any resident with a wound or indwelling device during encounters when contact is expected, including during wound care, the care of feeding and tracheostomy tubes, transferring residents and changing linens. Standard precautions such as hand hygiene always apply and precautions include the use of protective gowns and gloves during the high-risk activities. Clinical record review revealed that Resident 8 had diagnoses that included respiratory failure requiring a tracheostomy, history of a stroke, quadriplegia, dysphagia requiring a feeding tube, and neurogenic bladder requiring an indwelling catheter.…

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 a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a manner that prevented unauthorized access on one of two nursing units. (Second floor) Findings include: Review of the facility policy entitled, Storage and Expiration Dating of Medications and Biologicals, last reviewed August 1, 2024, revealed that medications and biologicals, including treatment items, were to be securely stored in a locked cabinet/cart or locked medication room that is unaccessible by residents and visitors. Observation on June 2, 2025, at 10:20 a.m., on the second floor nursing unit, revealed that the treatment cart in the hallway was unlocked and unattended and contained several tubes of medicated creams for pain, bottles of saline solution for nose and eyes, and boxes of alcohol pads that were accessible. In an interview on June 2, 2025, at 10:30 a.m., the RN Supervisor confirmed that the treatment cart should have been locked. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity for one of 22 sampled residents. (Resident 79) Findings include: Clinical record review revealed that Resident 79 had diagnoses that included rheumatoid arthritis, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and had limitations on both sides of his upper extremities. The care plan identified that the resident had a self-care deficit related to muscle weakness and contractures. There was an intervention for staff to provide total assistance with eating. Observation of the lunch meal on the 2nd floor nursing unit on February 26, 2025, at 12:08 p.m., revealed Resident 39 and Resident 79 seated in their room awaiting lunch. At 12:12 p.m., Resident 39 was served and eating their meal. Resident 79 was observed without a meal 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 clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 22 sampled residents. (Resident 85) Findings include: Clinical record review revealed that Resident 85 had diagnoses that included congestive heart failure, pulmonary hypertension, and chronic kidney disease. A physician's order dated January 30, 2025, directed staff to weigh the resident daily. A review of the Medication Administration Record (MAR) for February 2025, revealed that there was no evidence that staff weighed Resident 85 as ordered on February 9, 11, 15, 16, and 25, 2025. In an interview on February 27, 2025, at 10:58 a.m., the Director of Nursing confirmed that there was no documented evidence that the resident was weighed as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Use-By Guide-Quick Reference, last reviewed March 16, 2023, revealed that the use-by date marked on a container should be followed and that time/temperature control for safety directed that foods (milk and meat items) would not be held more than seven days. Review of the facility's policy entitled, Storage of Dry Food Policy, last reviewed March 16, 2023, revealed that containers holding food removed from the original packaging were to be labeled and dated. Observation during the kitchen tour on January 30, 2024, at 9:40 a.m., revealed the following: In the dessert cooler, there was a pitcher of water with lemon slices in it and six small dishes of various salad dressings that were not dated. There was a container of frosting that was dated January 18, 2024. In the cook's cooler, there was an open container of cottage cheese 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician of an incident for two of 23 sampled residents. (Residents 75, 109) Findings include: Review of the facility policy entitled, Resident Change in Condition, last reviewed March 16, 2023, revealed that the physician would be notified as soon as the nurse identified a change in condition, accident, or incident. The nurse would record the notification in the resident's health record. Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, senile degeneration of the brain, and repeated falls. Review of a nurse's noted dated November 30, 2023, revealed that Resident 75 had a fall. There was no documented evidence that the resident's physician was notified of the fall. In an interview on February 2, 2024, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence…

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 and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 23 sampled residents. (Resident 67) Findings include: Clinical record review revealed that Resident 67 was admitted to the facility on [DATE], with diagnoses that included hallucinations and dementia with mood disturbances, anxiety, and behavior disturbances. The Minimum Data Set assessment Care Area Assessment (CAA) summary dated December 30, 2023, noted that the resident's psychotropic drug use was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 67's psychotropic drug use were included in the care plan. In an interview on February 2, 2024, at 9:40 a.m., the Regional Nurse confirmed that there was no documented evidence that the identified care area (psychotropic drug use) was addressed in Resident 67's current care plan. 28 Pa. Code…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 23 sampled residents. (Resident 3) Findings include: Review of the facility policy entitled, Pain Management, last reviewed March 16, 2023, revealed that non-pharmacological interventions would be attempted prior to the administration of an as needed pain medication. Interventions for pain would be monitored for effectiveness in the electronic medication record. Clinical record review revealed that Resident 3 had diagnoses that included rheumatoid arthritis and muscle weakness. A physician's order dated January 15, 2024, directed staff to administer the narcotic pain medication, oxycodone, every four hours as needed for pain rated at four through seven of ten. Review of the care plan revealed the resident had chronic pain and interventions included that staff offer relaxation techniques to assist with pain…

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.