Heisinger Bluffs Rehab and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Heisinger Bluffs Rehab and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 6, 2022

  Based on observation, interview, and record review, facility staff failed to provide protective oversight for one resident (Resident #1) when the resident exited the facility without staff knowledge and a community member called the facility to report the resident off the facility property. Staff failed to follow their elopement policy when a door alarm sounded. Staff failed to conduct a head count to see if anyone was unaccounted for and the alarm was silenced without staff implementing elopement procedures. The facility census was 49. The administrator was notified on 06/02/2022 at 4:45 P.M., of an Immediate Jeopardy (IJ) which began on 05/30/2022. The IJ was removed on 06/03/2022 as confirmed by surveyor onsite verification. 1. […]

• No harm, potential for more than minimal, widespreadF812Mar 28, 2025

  Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff also failed to properly wash, sanitize and air-dry mechanically washed dishes to prevent cross-contamination and the growth of foodborne pathogens. This has the potential to affect all residents. The facility census was 55. 1. Review of the facility's Receiving and Storage of Food Policy, dated ,d+[DATE], showed: -Foods shall be received and stored in a manner that complies with safe food handling practices; -Food in designated dry storage areas shall be kept off the floor (at least 18 inches); -Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). […]

• No harm, potential for more than minimal, widespreadF812Mar 22, 2024

  Based on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary, using approved techniques to prevent cross-contamination. The facility census was 54. 1. Review of the facility supplied policies and procedures, showed the records did not contain a food service hand hygiene policy. Observation on 03/19/24 at 10:00 A.M., showed dietary aide (DA) G washed soiled dishes in the mechanical dishwashing station and then, without performing hand hygiene, the DA put away sanitized dishes from the clean side of the station. Observation on 03/19/24 at 10:32 A.M., showed DA G washed soiled dishes in the mechanical dishwashing station. […]

• No harm, potential for more than minimal, widespreadF880Mar 22, 2024

  Based on interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure all residents were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs, when staff failed to ensure a two-step Mantoux test (a skin test to determine whether a person in infected with determining whether a person is infected with tuberculosis) was completed and documented in accordance with their policy for three (#4, #6, and #9) out of six sampled residents. The facility census was 54. 1. […]

• No harm, potential for more than minimal, patternF803Mar 28, 2025

  Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to 33 of 55 residents (Residents #3, #4, #5, #6, #7, #8, 10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #28, #29, #30, #32, #34, #36, #37, #40, #42, #45, #46, #48, #51 and #58). The facility census was 55. 1. Review of the facility's Food and Nutrition Services Policy, dated 04/30/24, showed: -Each resident is provided with a nourishing, palatable, well-balance diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional… […]