Carbondale Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to ensure a resident was free from chemical restraint by failing to ensure a physician-ordered as-needed (PRN, meaning medication administered only when symptoms occur rather than on a routine schedule) psychotropic antianxiety medication was time-limited to 14 days or supported by documented physician rationale for continued use, including periodic reassessment of ongoing need, for one of 25 residents reviewed (Resident 28).Findings include: A review of the facility policy entitled Use of Psychotropic medications dated as reviewed January 7, 2026, included but was not limited to Psychotropic medications used on a PRN (as needed) basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: PRN medication orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending…

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 clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to implement procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one out of 25 residents reviewed (Resident 28). Findings include: A review of the facility policy titled Medication Administration, last reviewed by the facility on January 7, 2026, revealed that medications are to be administered by licensed nurses or other staff authorized to do so by the state, as ordered by the physician, and in accordance with professional standards of practice to prevent contamination, infection, and medication errors. The policy further requires that the licensed nurse administering a medication immediately document the resident's name, date and time of administration, dose, route of administration (how the medication enters the body, such as by mouth), and the signature of the nurse on the medication administration record. The policy requires…

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 select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in three of four medication storage locations observed (200 Hall Cart, Medication Storage Fridge, and 100 Hall cart).Findings include: A review of the facility policy titled Insulin Pen, last reviewed by the facility on January 7, 2026, revealed that insulin pens contain multiple doses of insulin (a medication used to lower blood sugar levels) but are intended for use by a single resident only. The policy indicated insulin pens must be clearly labeled with the resident's name, physician's name, date dispensed, type of insulin, dosage amount, frequency of administration, and expiration date. The policy further indicated that once a multi-dose insulin pen is opened, it must be discarded after 28 days or according to the manufacturer's recommendation. The policy specified that if a required label is missing, the pen is not to be used, and a replacement must be obtained…

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 a review of clinical records, resident financial documentation, and staff interview, it was determined the facility failed to safeguard, manage, and accurately account for the personal funds of one resident (Resident 40) out of 23 residents reviewed Findings include: A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the lung (an abnormal growth of cells characterized by uncontrolled and rapid growth, invasion of surrounding tissues, and the potential to spread to other areas of the body). A clinical record review revealed Resident 40's payor source is Medicaid (a joint federal and state program that helps cover medical costs for some people with limited income and resources. Individuals on Medicaid receive a Personal Needs Allowance- a monthly stipend to cover personal expenses. As of January 1, 2025, the PNA for Pennsylvania is $60 for residents residing in long-term care facilities). A review of a quarterly Minimum…

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 a review of clinical records and select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening, and the development of pressure sores for one resident out of 23 residents sampled (Resident 57). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. The largest medical specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines indicate that the treatment of pressure ulcers should…

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, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 23 residents sampled (Resident 40). Findings include: A review of the facility policy titled Restorative Nursing Program, last reviewed by the facility on January 10, 2025, revealed it is the facility's policy to provide maintenance and restorative services designed to maintain or improve residents' ability to the highest practicable level. The restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Residents will receive services from restorative when they are assessed to have a need for restorative nursing services. A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that included…

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 select facility policy, and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and in two of two resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of a facility policy titled Use and Storage of Food Brought in by Family or Visitors, last…

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 a review of clinical records, select facility reports and staff interview it was determined the facility failed to investigate the origin and promote the healing of a pressure sore for one of six residents sampled (Resident 1). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer…

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 clinical records and staff and family interview, it was determined the facility failed to consistently monitor resident weights to timely identify and act upon a resident's weight loss, and implement necessary nutritional support to promote acceptable nutritional parameters for one resident out of 6 sampled (Resident 1). Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include, lumbar radiculopathy (severe pain that radiates from the back into the hip and outer side of the leg caused by compression of a nerve), dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and a history of falling. A review of an admission Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed the resident had a Brief Interview for Mental Status score of 7 (BIMS…

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 the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined that the facility failed to fully develop and implement established abuse prohibition procedures for screening five of five employees for employment (Employee 1, 2, 3,4 and 5) Findings include: According to regulatory requirements under §§483.12(a)(3) and 483.12(b)(1)] the facility must have written procedures for screening for prospective employees, to include reviewing: the employment history (e.g., dates of employment position or title), particularly where there is a pattern of inconsistency; information from former employers, whether favorable or unfavorable; and/or documentation of status and any disciplinary actions from licensing or registration boards and other registries. A review of the facility's Resident Abuse policy last reviewed by the facility January 3, 2023, revealed no procedures for screening potential employees that included obtaining references from current/previous employers. Review of employee personnel files revealed that Employee…

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 clinical records and staff interviews it was determined that the facility failed to ensure the presence of current documented clinical necessity of a resident's continued use of an psychotropic medication prescribed on an as needed basis for one resident out of five sampled (Resident 65). Findings included: A review of the clinical record revealed that Resident 65 had diagnoses of Parkinsons disease (a progressive neurological disease), dementia, and a history of falling. The resident was placed on Hospice services November 24, 2023, for end stage Parkinson's disease. The resident had a physician order dated January 9, 2024, for Haldol, an antipsychotic medication, 2 mg/ml, SL (sublingual, under the tongue), 1 ml, SL every 6 hours for anxiety/terminal agitation (a common symptom of dying, characterized by sudden agitation, anxiety, anger or confusion). There was no corresponding physicians documentation or any documentation from hospice staff of related to the resident's need for this newly added antipsychotic medication, and the resident's anxiety/terminal…

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 select facility policy, clinical records, and incident reports and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events, as evidenced by multiple falls incurred by one resident out of 18 sampled (Resident 65). Findings include: Review of the facility policy entitled Quality assessment and improvement plan last reviewed by the facility January 9, 2024 revealed that the facility is committed to incorporating the principles of Quality Assurance and performance Improvement (QAPI) into all aspects of the center work processes, services lines and departments. All staff and stakeholders are involved in QAPI to improve the quality of life and quality of care that out patients and residents experience. The process included: - The administrator directs the development and documentation of the center QAPI plan, including an annual QAPI…

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 clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of 21 residents reviewed (Resident 90). Findings include: According to the RAI User's Manual dated October 2023 a Significant Change in Status MDS assessment is required within 14 days of the determination of the significant change when: A resident enrolls in a hospice program; or A resident changes hospice providers and remains in the facility; or A resident receiving hospice services discontinues those services; or A resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident's current status to the most recent CMS-required MDS). A review of the clinical record of Resident 90 revealed that the resident had experienced a significant…

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 observations, clinical record review and staff and resident interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis for one of 21 residents sampled. (Resident 52) Findings include: According to the National Kidney Foundation patients receiving hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) should keep emergency care supplies on hand. A review of Resident 52's clinical record revealed that the resident was admitted to the facility was on May 11, 2017, with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of the resident's current plan of care, dated October 8, 2021, revealed that the resident required dialysis related to renal failure along with a care planned approach to have 4 x 4 gauze pads and cloth tape were to be at the bedside. Observations conducted on July 11, 2024, at 10:17 AM revealed no emergency supplies were available in 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.