St. Monica Center for Rehabilitation & Healthcare

Inspectors wroteBased on review of facility policy, review of clinical record, observations, and interview with staff, it was determined that the facility failed to review and revise one care plan related to restorative nursing program for one of 33 residents reviewed (Resident R17). Findings Include:Review of facility policy titled Interdisciplinary Care Planning Protocol, dated July 2025, revealed that Problems established by the team with resident/family input MUST be specific and individualized meaning as resident changes are noted, the resident plan of care must be revised. Review of resident records revealed that Resident R17 was admitted to the facility on [DATE], and had diagnoses including, but not limited to, atrophy (muscles decreasing in size, typically due to disuse), muscle spasms, and periodic paralysis. Observation on June 11, 2026, at 11:17 a.m. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to ensure residents were free from accident/hazards and received adequate supervision related to eating and medication administration for two of 33 residents reviewed (Resident R169 and R8).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and interview with staff it was determined that the facility failed to ensure proper labeling of medications for one of 33 residents reviewed (Resident R175). Findings Include:

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure complete and accurate documentation related to a Neurological Assessment Flow Sheet for one of 33 residents reviewed (Resident 187). Findings Include:Review of facility documentation Neurological Assessment Flow Sheet Instructions revealed staff should record the date and time of each assessment then proceed to document the appropriate response as follows: level of consciousness, pupil response, motor functions (hand grasps/extremities), pain response and vitals. Per the Neurological Assessment Flow Sheet vital signs and neurological checks should be completed per protocol: every fifteen minutes for one hour, every thirty minutes for one hour, every hour for four hours, and then every four hours for twenty-four hours. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement proper infection control practices related to enhanced barrier precautions for one of 33 residents reviewed (Resident R175).

Inspectors wroteBased on observation, review of clinical records, review of facility policy, interview with staff and residents, it was determined that the facility failed to develop a comprehensive person-centered care plan related to COPD (chronic obstructive pulmonary disease), oxygen use and Anxiety/ Dementia Care for three of 35 residents reviewed. (Resident R22, Resident R143 and Resident 163). Findings Include: Review of facility policy on Interdisciplinary Care Planning Protocol revealed section All Admissions - Day of admission #2. Nursing Initiates Interim Care Plan - the interim care plan must address all immediate care needs. Under section Skilled Subacute Care Admissions #2. Interim care plan initiated on the day of admission must be reviewed by the IDCP team and modified by 8th day of admission. Under section Long Term Care Admissions -Within Fourteen Days #3. [...]

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interview with facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to serving meals on disposable paperware and plasticware for one of three units (3rd Floor) and for one of 35 residents reviewed (Resident R8)

Inspectors wroteBased on observations, staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a resident was properly assessed for the self-administration of a medication that was located in the resident's room for 1 out of 35 residents reviewed (Resident R160)

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one out of 35 residents sampled (Residents R60).

Inspectors wroteBased on observations, staff interviews, review of facility policy and the review of clinical records, it was determined that that the facility failed to ensure that a physician was notified of a rapid and significant weight gain, and failed to clarify a physician's order for 1 out of 35 residents reviewed (Resident R160)

Inspectors wroteBased on the review of clinical records, observations and staff interviews, it was determined that the facility failed to develop and implement interventions such as turning and repositioning or offloading of heels for resident with total dependence to prevent the development of a pressure ulcer for one of three residents reviewed (Resident R17). Review of Resident R17's clinical record revealed Resident R17 was readmitted to the facility on [DATE] with diagnoses of, but not limited to, Dementia (progressive degenerative disease of the brain) and Chronic Kidney Disease. [...]

Inspectors wroteBased on observations, review of facility policies, clinical record review and interview with staff and residents, it was determined that the facility failed to ensure that resident significant weight gain was assessed in a timely manner for one resident (Resident R160), and failed to ensure that the nutrition and hydration status were properly assessed related to the use of a PEG tube (feeding tube inserted into stomach) for another resident (Resident R10) for 2 out of 35 residents reviewed. Review of the facility policy Weight Assessment, Management and Intervention Procedure, with a date of 3/25, indicated that nursing staff will measure resident weight on admission and monthly or as ordered by physician and that any weight change of 5% or more since the last monthly weight assessment will be retaken for confirmation, and if the weight is verified, nursing will notify the Dietitian. [...]

Inspectors wroteBased on observation, review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that resident was administered oxygen according to physician's order for one resident of one resident reviewed on oxygen therapy. (Resident R158)

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were properly labeled and dated for two of three units reviewed (Second floor unit, First floor St. [NAME] unit) and properly stored for one of one resident observed with medication in the room. (Resident R160)

Inspectors wroteBased on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E7).

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of 35 residents reviewed (Residents R18, R22, R60, R104, and R187).

Inspectors wroteBased on a review of facility documents and interviews with staff, it was determined that the facility failed to ensure that terms of a binding arbitration agreement included required language to protect the rights of the resident or resident representative.

Inspectors wroteBased on staff interview, review of hospice documentation and review of clinical records, it was determined that the facility failed to ensure that a recommendation from the contracted hospice agency related to a resident's medication management was addressed and/or implemented for 1 out of 1 hospice record reviewed (Resident R90).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to dispose of garbage and refuse properly where food and laundry is received. Findings Include: On September 27, 2024, 11:27 a.m., reviewed the dumpster area in the presence of the Director of Environmental Services, Employee E16 (dumpster is a large trash receptacle designed to be hoisted and emptied into a truck). The dumpster was leaking and oozing creamy colored, foul odorous liquid, through the sides of the dumpster, over the floor, around the dumpster, where the floor was irregularly covered with dark greasy appeared substances. At the time of the finding, E16 confirmed the observation. 28 Pa.

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure two residents were free from significant medication errors for two of three residents reviewed. (Resident R24, and Resident R101)

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to address the potential for developing a pressure ulcer and develop/implement a plan of care to prevent pressure ulcers for one of 34 residents reviewed (Resident R145). Findings Include: Review of undated facility policy Care Planning Protocol revealed nursing provides an overview of medical and nurse care regimes. Nursing provides input especially related to activities of daily living, skin, weights, and safety needs. Care Are Assessment Summary triggers are reviewed by the team to decide whether to proceed with care planning for each triggered area. [...]

Inspectors wroteBased on facility policy, observation, and staff interviews, it was determined the facility failed to ensure the resident's environment remained free of accidents and hazards relating to medication found at bedside for one of seven residents observed. (Resident R 153)

Inspectors wroteBased on review of clinical records, observations, interviews with staff and residents, it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one out of three sampled residents receiving hemodialysis (Resident 141).

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interview. it was determined that the facility failed to develop and implement procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications to meet resident needs for one of 34 residents reviewed (Resident R117). Findings Include: Review of Resident R117's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 22, 2024, revealed the resident was cognitively impaired and had a diagnosis of anxiety (a feeling of worry, nervousness, or unease). Review of Resident R117's comprehensive care plan dated October 5, 2022, revealed the resident used anti-anxiety medications related to anxiety disorder. Intervention dated December 8, 2020, included to give anti-anxiety medications as ordered. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure the attending physician timely reviewed identified irregularities and failed to document the action taken to address the irregularities for two of five residents reviewed (Resident 117 and 144). Findings Include: Review of undated facility policy Consultant Pharmacist revealed the consultant pharmacist will establish a system whereby the consultant pharmacist's observations and recommendations regarding the resident's drug therapy are communicated to the appropriate designee to implement and/or respond to the recommendations in an appropriate and timely fashion. Further review of facility policy revealed the timing of these recommendations should enable a response prior to the next drug regimen review. [...]

Inspectors wroteBased on review of facility documentation and clinical record review it was determined that the facility failed to ensure documentation for the need for a medication to treat a specific diagnosed condition with use of a psychotropic medication for one of five residents reviewed (Resident R117). Findings Include: Review of Resident R117's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 4, 2024, revealed the resident was cognitively impaired and had diagnoses of anxiety and depression. During the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medications. [...]

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of six residents observed during medication administration (Resident R29, and R151).

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to obtain laboratory services to meet resident needs for one of 34 residents reviewed (Resident R10). Findings Include: Review of Resident R10's significant change Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 2, 2024, revealed the resident had a diagnosis of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior). Review of Resident R10's comprehensive care plan dated July 18, 2024, revealed the resident had potential for episodes of anxiety (a feeling of worry, nervousness, or unease) related to disease process, schizophrenia. Intervention included psychological consultation and treatment as needed. [...]

Inspectors wroteBased on review of facility policy, review of clinical records and interview with staff and residents, it was determined the facility failed to provide dental services in a timely manner for one of eight residents reviewed.(resident R 97)

Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to hand hygiene, appropriate cleaning techniques for medical equipment, for four of the six residents observed during medication administration pass. (Resident 8, Resident 24, Resident 46 and Resident 155)

Inspectors wroteBased on observations, interview with residents, residents' family members and staff, as well as review of facility's documentation, it was determined that facility did not ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, and plan of care for three of 34 residents reviewed. (Residents R69, R56)

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for three of five residents reviewed (Residents R1, R4 and R5).

Inspectors wroteBased on observations, interviews with residents and staff, review of facility policy, and review of facility documentation, it was determined the facility failed to ensure that call bells were available and working for five of five units observed. (St. [NAME], St. [NAME], St. [NAME], St. [NAME] , and St. [NAME] De [NAME]). Findings Include: Review of facility policy Call Bell Policy and Procedure dated 2/20 stated Resident will have functioning call bells to alert staff of their needs. Interview with Resident R2 on September 11, 2023 at 10:15 a.m. revealed the resident's call bell has not been working. The resident stated that the call bell has not been working for a few days now. Resident R2 stated that a nurse came in and gave him a call bell this morning but that other people have had their bells for a few days now. The call bell was tested at 10:21 a.m. [...]