St Martha Center For Rehabilitation & Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's policy, a clinical records review, observations, and staff interviews, it was determined that the facility failed to comprehensively investigate an injury of unknown origin for one of the two residents reviewed (Resident 1). Findings: A review of the facility's policy titled Abuse Prevention/Reporting, revised on February 25, 2025, revealed that procedures have been developed and implemented to properly screen, report, protect, investigate, and correct issues relating to abuse. Staff are trained to determine types of abuse, stress management tips, and recognition of signs and symptoms of abuse, which may include, but are not limited to, the following: bruises, skin tears, welts, etc., of unknown origin, unexplained injuries. The same policy revealed: The following is a list of methods to be used to conduct the investigation: Review of records; Observe and interview residents, staff members, accused personnel, witnesses, family members, and visitors; Compile written…

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 facility's policy, clinical records review and staff interviews, it was determined that the facility failed to comprehensively and accurately assess pain and provide pain management for one of two residents reviewed (Resident 1). Findings:A review of the facility's policy titled Pain Management, revised date May 2024, revealed Procedure in recognizing pain: Observe the resident during rest and movement for physiologic and behavioral (nonverbal) signs of pain. Evaluating pain: During the pain evaluation gather the following information; characteristic of pain (1) Intensity of pain (as measured on a standard pain scale) (2) description of pain (3) pattern of pain (4) location of pain and (5) frequency, timing and duration of pain. The same policy revealed Implement the medication regimen as ordered, documenting the results of the intervention.A review of Resident 1's diagnosis list includes Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain), Alzheimer's disease (irreversible, progressive degenerative disease of the brain,…

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 records review and staff interviews, it was determined that the facility failed to follow physician orders regarding oxygen and catheter care for 1 of 8 resident's reviewed (Resident 10).Findings include: Review of Resident 10's face sheet revealed medical diagnoses that include Obstructive and Reflex Uropathy (blockage in urinary tract), Urine Retention, Atrial Fibrillation (irregular often very rapid heart rhythm). Review of Resident 10's physician orders revealed orders dated September 5, 2025, to provide foley catheter care every shift. Review of Resident 10's December 2025, Medication Administration Report (MAR), revealed orders for foley catheter care every shift were not followed on December 2, 2025, day and evening shift, December 4, 2025, day shift, December 5, 2025, day shift, December 7, 2025, day shift, December 8, 2025, evening shift, December 9. 2025, day shift, December 12, 2025, day and evening shift, December 13, 2025, day shift, December 15, 2025, evening shift, December 20, 2025, evening shift, December 21, 2025,evening shift, December 22, 2025,…

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, observations, clinical records and staff interviews, it was determined that the facility failed to follow physician orders for two of 22 residents reviewed (Resident 86 and 164). Finding include: A review of the facility's policy regarding Enteral Nutrition, dated March 2020, revealed adequate nutritional support through enteral feeding will be provided to residents as ordered. A review of Resident 86's clinical records revealed medical diagnoses that include Dysphagia following other Cerebrovascular Disease (swallowing disorder that occurs after a stroke or other neurological disease), Muscle Wasting and Atrophy (loss of muscle mass), and Severe Protein-Calorie Malnutrition (inadequate protein or calories in diet). Review of Resident 86's clinical records revealed a physician order dated January 9,2025, for Jevity 1.5 at 40ml/ per hour x20 hours via Kangaroo pump (pump that delivers nutrition through a tube inserted in the stomach or intestine that's programmed with desired feed rate and volume), total volume 800ml per day or until infused.…

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 records review and staff interview, it was determined that the facility failed to ensure appropriate indications and non-pharmacological interventions were provided before administering as-needed anti-anxiety medications for two of five residents reviewed (Residents 3 and 22). Findings include: A review of Resident 3's physician's order dated May 24, 2024, revealed an order for Ativan (anti-anxiety medication) gel 1mg/ml applied to the base of the neck topically two times a day for Anxiety. On September 24, 2024, an order for Ativan gel 1mg/ml applied to the neck every eight hours as needed for anxiety was ordered aside from the routine Ativan gel. A review of the November 2024, Medication Administration Record revealed that from November 1, 2024, until November 30, 2024, as needed Ativan gel was administered to Resident 3 seven times with no appropriate indication and was administered five times without attempting a non-pharmacological intervention. A review of Resident 22's physician's order dated January 16, 2025, revealed an order for Clonazepam 0.5 mg…

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 policy and procedure review, and staff interview it was determined the facility failed to obtain weights to maintain residents' nutritional status for four of 14 residents reviewed. (Residents 26, 74, 109, and 113) Findings Include: Review of facility policy and procedure titled Resident Weights, revised May 2022, revealed the nursing staff will measure residents' weights during the admission process which can take up to 24 to 48 hours from admission date. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each resident electronic medical record. Any weight change of 5% or more since the last weight assessment will be retaken. If the weight is verified, nursing will notify the Dietitian. Review of Resident 26's diagnosis list revealed a diagnosis of Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Cerebrovascular Accident (CVA- Stroke), Cerebral…

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 records review, resident and staff interview, it was determined that the facility failed to implement a comprehensive care plan intervention to prevent alteration in nutrition and hydration for one of eight residents reviewed (Resident R14). Findings include: Review of R14's records revealed a care plan dated May 12, 2020, documenting the resident has potential for self-care deficit. Interventions included resident requires eating assist x one person. Further review of R14's records revealed a care plan dated May 12, 2020, with a revision date of November 17, 2023, documenting R14 has the potential for alteration in nutrition and hydration. Intervention dated March 29, 2022, documented the need for staff to assess R14's ability to prepare food/fluids and feed self. Interventions also included the need to offer the resident assistance as needed. An intervention dated September 6, 2023, documented the need for adaptive equipment: lipped plate with meals. Observation of R14 on January 10, 2024, at 09:02 AM, revealed the resident having difficulty eating. The 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 clinical record review and staff interview it was determined the facility failed to complete a discharge summary for a planned discharge for one of one residents reviewed. (Resident 112) Findings Include: Review of Resident 112's Physician Orders revealed an order dated January 8, 2024 for the resident to be discharged to a group home on January 8, 2024. Review of Resident 112's entire clinical record revealed there was no discharge summary completed upon discharge. Interview with the Director of Nursing on January 12, 2023 at 11:30 a.m. confirmed there was no discharge summary completed upon the discharge of Resident 112. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(3) Management 28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure physician orders regarding medications were followed for two of the 24 residents reviewed (Residents 26 and 97). Findings include: Review of Resident 26's diagnosis list revealed a diagnosis of Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Cerebrovascular Accident (CVA- Stroke), Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain). Review of Resident 26's clinical records revealed Resident 26 had a Gastrostomy Tube (GT- A tube inserted through the belly that brings nutrition directly to the stomach) due to Dysphagia (Difficulty swallowing). Review of Resident 26's physician order (POS) revealed an order initiated on December 20, 2023, for Insulin Gargline (Long-acting insulin) Subcutaneous Pen-Injector 100 unit/ml Inject 24 units subcutaneously at bedtime. Review of Resident 26's December 2023 Medication Administration Record (MAR) revealed resident was not administered with 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.

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 ensure the pharmacy services provided medications timely for two of the 24 residents reviewed. (Resident 26 and 102) Finding include: Review of Resident 26's clinical record revealed Resident 26 was readmitted to the facility on [DATE]. Review of Resident 26's physician order (POS) dated December 20, 2023, revealed an order for Onfi Oral Suspension (A medication used to treat seizures) 2.5 mg/ml given 3 ml every 12 hours for Seizures. The medication was scheduled for 9:00 a.m. and 9:00 p.m. Review of Resident 26's December 2023 Medication Administration Record (MAR) revealed that the Onfi medication was not administered to the resident until the morning of December 25, 2023, five days after the medication was ordered. MAR review revealed that the resident had missed a total of nine doses of the Onfi medication. Interview with the Director of Nursing was conducted on January 12, 2024. The DON reported that 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 clinical records review and staff interview, it was determined that the facility failed to ensure that laboratory test was obtained as ordered by the physician for one of the 24 residents reviewed (Resident 35). Findings include: Review of Resident 35's diagnosis list includes Heart Failure and Atrial Fibrillation (A-fib- An irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 35's clinical records review revealed resident was receiving Jantoven (Warfarin) for blood clot prevention. Review of the Physicians order dated October 23, 2023, revealed an order for PT (Prothrombin Time- a test that measures how long it takes for a clot to form in a blood sample) and INR (International Normalized Ratio- a type of calculation based on PT test results) every other day, call the physician for INR >3, INR<1.5. Review of Resident 35's clinical records revealed that INR was done on October 25, 2023, but failed to reveal that the INR test was done on October 27, 2023. Clinical records review failed to reveal that the physician was notified that 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 resident and staff interviews, observations, and facility documentation review it was determined the facility failed to have adequate number of dietary staff to meet the needs of the residents. Findings Include: Interviews conducted with Resident R1, R2, R3, R4, and R5 on August 29, 2023 between 9:15 and 9:50 a.m. revealed the breakfast trays are always late for the residents and arrive between 9:15 a.m. and 10:15 a.m. Observations of the breakfast tray delivery on August 29, 2023 revealed the last tray was delivered to a resident on the 600 hall at 10:10 a.m. Observation of the dining room during the breakfast meal revealed the dining room was not being used and a sign was posted to the door that it opens at 8:15 a.m. Interview with Dietary Director Employee E3 on August 29, 2023 at 10:35 a.m. revealed the kitchen was short staffed the day of the survey. The kitchen should be staffed with three staff on tray line, on staff member to pushed the completed carts to the units and one cook and one dishwasher, today the kitchen was staffed with one staff on tray line, on to push…

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.