Immaculatemarycenter for Rehabilitation&Healthcare

In the surveyor’s words

From the most serious findings on record at Immaculatemarycenter for Rehabilitation&Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 3, 2025

  Based on review of clinical record, facility policies, facility documentation, and interviews with staff, it was determined the facility failed to provide adequate supervision for one of 13 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third-floor lockdown unit, accessing the elevator to the lobby, and walking out the front entrance of the facility. Resident R1 was located approximately two hours later at a family members residence, approximately 1.2 miles away from the facility. Resident R1 accessed a busy traffic area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy situation. […]

• Actual harm, isolatedF689Mar 1, 2021

  Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to provide the appropriate level of supervision to one of four residents reviewed, resulting in actual harm to Resident CL1, who sustained a second degree burn from a hot liquid. Findings include: Review of Resident CLl's closed clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnoses of dementia with behavioral disturbances, [CONDITION(S)] (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and diabetes (failure of the body to produce insulin to enable sugar to pass form the blood stream to cells for nourishment). […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2021

  Based on observations, review of facility policy 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. Findings include: Review of facility policy Subject: Food Handling dated March 2020, revealed Foods are stored, prepared and served in a safe and sanitary manner with the purpose is to prevent bacterial contamination and the spread of infection. An initial tour of the Food Service Department was conducted on November 1, 2021, at 10:05 a.m. […]

• No harm, potential for more than minimal, patternF584Apr 17, 2025

  Based on observation and interview with staff, it was determined that facility did not ensure to provide a safe, clean, sanitary and homelike environment for five of 51 rooms observed (Room#'s 200-B, 207-B, 209-B, 210-B, 425-B) Findings include: Review of facility policy 'Homelike Environment,' indicates that residents are to be provided with a safe, clean, comfortable and homelike environment Observations on 2nd floor unit, on Monday, April 14, 2025 at 10:30 am, in room [ROOM NUMBER]-B, revealed two used wash cloths on floor in front of resident's bed, unemptied trash bin, and unemptied bed side commode. Further observations in room [ROOM NUMBER]-B, at 11:00 am, revealed overflowing trash bin as well as excess trash on floor, three separate liquid areas on floor. […]

• No harm, potential for more than minimal, patternF644Apr 17, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to refer a resident with a newly diagnosed mental disorder for level II of the PASRR (Pennsylvania Pre-Admission Screening Resident Review) or three of three residents reviewed (Residents R119, R174, and R184). Findings include: The PASRR (Pennsylvania Pre-Admission Screening Resident Review), federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care, dated March 1, 2009, lists examples of serious mental illness including mood disorder, bipolar, and depression. […]