Heinz Transitional Rehabilitation Unit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records, select facility policy, and staff interview, it was determined that the facility failed to fully implement enhanced barrier infection control procedures to prevent spread of infection for three of 14 sampled residents (Residents 13, 43, and 33). Findings include: According to the Centers for Disease Control (CDC) Enhanced Barrier Precautions (EBP) guidance focuses on gown and glove use and other important infection control measures for prevention of multi-drug-resistant organisms (MDRO type of bacteria or microorganism that has developed resistance to multiple classes of antibiotics, making infections harder to treat). EBP are recommended for residents with any of the following: infection or colonization with a MDRO, a wound, or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Review of the facility Enhanced Barrier Precautions Policy last reviewed/revised November 1, 2024, indicated it is the facility policy…

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, facility policy, observation, and staff interview it was determined the facility failed to ensure the resident environment was free from potential hazards for one of 14 sampled residents (Resident 56).Findings included: A facility policy titled 'Self-Administration of Medications', last reviewed on November 1, 2024, revealed the organization promotes the right to self-administer drugs unless the team has determined that the practice would be unsafe. The policy indicated if it is deemed safe and appropriate for a resident to self-administer medications, self-administration of medication is documented in the medical record and the care plan. A facility policy titled 'Procedure for Medication Administration', last reviewed on November 1, 2024, indicated the purpose of the procedure is to guide safe medication administration. The policy further stated the licensed nurse will remain with the resident while he/she swallows oral medication, follow with a drink to clear the oral…

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 interviews, it was determined the facility failed to develop person-centered care plans that included management and refusal of a Wound Vacuum (a type of therapy to help wounds heal) for one resident out of 12 sampled (Resident 16). Findings include: A review of the clinical record revealed Resident 16 was admitted to the facility on [DATE], with diagnoses to include acquired absence of left toes, and end stage renal disease (a chronic kidney disease that occurs when the kidneys are permanently damaged and can no longer function) which required dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly). A review of the clinical record revealed a physician order dated November 18, 2024, for continuous wound vac therapy to left medial foot with settings of 120 mmHg pressure intensity. Begin at 6 and decrease to 3 if resident is unable to tolerate (i.e. pain). A review of Resident 16's progress note…

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 staff interview, it was determined the facility failed to follow physician orders for administration of antibiotic and provide care to a PICC line as ordered for one resident out of 12 sampled. (Residents 18). Findings include: A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses which included intraspinal abscess and granuloma (a condition where a collection of pus forms within the spinal canal, alongside the development of a small inflammatory nodule [granuloma] both occurring within the spinal column), urinary tract infection, and heart disease. Further review of the resident's clinical record revealed Resident 18 was admitted with a PICC line (peripherally inserted central catheter inserted into a vein in the arm and threaded into a large vein above the heart) for intravenous (through a vein) antibiotic therapy. A review of Resident 18's physician orders dated November 3, 2024, revealed an order for…

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 and protocol, and resident and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for the bowel protocol prescribed for three residents out of 13 sampled (Residents 21, 176 and 82) to promote normal bowel activity to the extent possible. Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the facility policy titled Bowel Elimination Protocol, last reviewed by the facility on November 2, 2023, indicated that the facility will record bowel movements 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview it was determined that the facility failed to demonstrate that a resident was afforded the right to participate in care planning to meet the resident's nutritional needs and had incorporated the resident's personal preferences for weight loss and assure the resident received items included in the plan of care, to include snacks and additional protein, for one resident out of 13 sampled (Resident 13). Findings included: Review of Resident 13's clinical record revealed admission on [DATE], with diagnoses of orthopedic aftercare, pneumonia, and diabetes. A review of an admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated December 26, 2023, indicated that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). 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 observation, review of select facility policy and clinical records and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer medication (Lantus Insulin) for one of 13 residents reviewed (Resident 13). Findings include: A review of facility policy entitled Procedure for Medication Administration, and Self Administration of Medications, last reviewed by the facility November 2, 2023, indicated it is the policy to safely administer medications to the resident as ordered by the physician. Medications are not to be left bedside. It is the policy to promote the right of the resident to self administer drugs unless the interdisciplinary team (IDT) has determined that this practice would be unsafe. To assist in safe self administration the IDT will consider are the medications appropriate and safe for self administration, does the resident have the ability to ensure that the medications is stored safely and securely in a locked cabinet…

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, clinical record review and staff and resident interviews, it was determined that the facility failed to develop person-centered care plans that included individual resident needs and preferences for self-administration of medication and potential for pain for two residents out of 13 sampled (Resident 13 and 3). Findings include: A review of the clinical record revealed Resident 3 was admitted to the facility December 11, 2023, for orthopedic aftercare. An Nursing admission Evaluation dated December 11, 2023, revealed the admission diagnosis as failure of recalled total hip arthroplasty hardware. Hospital discharge instructions dated December 11, 2023, prior to the resident's admission to the skilled nursing facility, indicated that had been hospitalized for a left hip arthroplasty because of a left hip hardware failure. A Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 18, 2023,…

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 and clinical records, and resident and staff interviews it was determined that the facility failed to provide a physician ordered nutritional supplement prescribed to one out of four sampled residents sampled (Resident 77). Findings include: Review of the clinical record revealed that Resident 77 was admitted to the facility on [DATE], with diagnoses which included left femur fracture (break in the thigh bone) with left hip hemiarthroplasty (surgical procedure similar to total hip replacement but only ball point of the hip joint is replaced). A physician order dated January 2, 2024, was noted for Juven (a powdered nutritional supplement mixed with water or juice to support wound healing and maintain lean body mass) with meals for supplement, but failed to indicate the amount of Juven to be provided to the resident at each meal. A clarification physician order dated January 4, 2024, noted an order for Juven 8 ounce with each meal. Further review of the clinical record…

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 resident and staff interview, it was revealed that the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 13 sampled (Resident 127) Findings include: A review of the clinical record revealed that Resident 127 was admitted to the facility on [DATE], with diagnoses to include left tibia fracture, diabetes, and depression. The resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental, {BIMS} which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The resident's care plan indicated that she was at risk for adverse reactions and behavior problems not easily altered related to current psychoactive medication date initiated on [DATE]. The goal was that the resident will be educated to use of medication and recognition of adverse reactions, along with interventions if adverse reaction occurs through…

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.