Heinz Transitional Rehabilitation Unit

In the surveyor’s words

From the most serious findings on record at Heinz Transitional Rehabilitation Unit, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Sep 25, 2025

  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). […]

• No harm, potential for more than minimal, patternF684Jan 5, 2024

  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… […]

• No harm, potential for more than minimal, patternF623May 6, 2021

  Based on clinical record reviews and staff interviews, it was determined the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and residents' responsible party for three of three residents reviewed (Residents 16, 21 and 123). Findings include: A review of the facility's written transfer/discharge notice revealed it did not include the reason for the transfer (in a manner and language they understand), a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request and For nursing facility residents with a mental… […]

• No harm, potential for more than minimal, isolatedF641Jul 9, 2026

  Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, resident interview, observation, and staff interview, it was determined the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one of four residents reviewed (Resident 42).Findings include: Facility Resident Assessment Instrument (RAI) User's Manual (October 2026), which provides instructions for completing the Minimum Data Set (MDS, a federally required standardized assessment used to evaluate resident status and develop care plans), indicates the assessment must accurately reflect the resident's functional status and be completed with participation from appropriate health professionals. […]

• No harm, potential for more than minimal, isolatedF656Jul 9, 2026

  Based on review of facility policy, clinical record review, resident interview, and staff interview, it was determined the facility failed to review and revise a comprehensive person-centered care plan following a change in treatment and resident preference regarding the continued use of an indwelling urinary catheter for one of four residents reviewed (Resident 2).Findings include: A review of the facility policy titled Resident Comprehensive Care Plan, last reviewed November 5, 2025, indicated a comprehensive care plan will be initiated for each resident and will include measurable objectives based on the resident's assessed needs. […]