Matulaitis Rehabilitation & Skilled Care

In the surveyor’s words

From the most serious findings on record at Matulaitis Rehabilitation & Skilled Care, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 1, 2022

  Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 4 residents (Resident #181 and 4) reviewed for falls, the facility failed to ensure a pelvic positioning belt was applied according to the care plan, and failed to ensure 2 staff were present when the resident was positioned and fastened to the mechanical lift, which resulted in Resident #181 falling forward out of the wheelchair and onto the floor and sustaining a comminuted femoral fracture, and for Resident #4 who was at risk for falls, the facility failed to ensure a rehabilitation screen was completed upon admission. The findings include: 1. Resident #181 was admitted to the facility with diagnoses that included [CONDITION(S)] and dementia. […]

• No harm, potential for more than minimal, patternF881Jul 2, 2026

  Based on review of facility documentation, review of facility policy/procedure, and interviews, the facility failed ensure that documentation was available to indicate that when antibiotics were prescribed, an assessment was completed on a consistent basis to indicate whether or not an adjustment was necessary in the prescribed medication. The findings include. The findings include:Review of the antibiotic stewardship program for the period of December 2024 through June 2026 with the Infection Preventionist (IP) RN #1 on 7/1/26 at 12:35 PM failed to identify consistent and timely documentation of reviews completed when antibiotics were prescribed to determine whether the antibiotic is still indicated or if adjustment needed to be made. […]

• No harm, potential for more than minimal, patternF812Dec 19, 2024

  Based on observation, staff interviews, and facility document review, the facility did not consistently complete sanitation logs for the sanitizing sink according to facility policy. The findings include: On 12/15/2024 at 10:15 AM a tour of the kitchen was completed with the facility dietary manager and assistant manager. A dietary aide was observed washing a pitcher in a 3-bay sink. There were two large gray baking pans soaking in the sanitizing sink (third bay from the left). The dietary aide indicated that she did not check the level of the sanitizer concentration because the cook checked it in the morning before the dishes were washed. […]

• No harm, potential for more than minimal, patternF812Mar 1, 2022

  Based on observation, review of facility documentation, facility policies and interview, the facility failed to ensure food items were consistently labeled and stored to reflect its age or shelf-life or failed to ensure food items and utensils were distributed on the tray line under sanitary condition. The findings included. 1. Observation on 2/23/22 at 11:01 AM during the initial walk-through of the kitchen with the Dietary Supervisor identified the following food items lacked documentation or labeling of a date to reflect the age or shelf-life of a food item. a. Observation of the large walk-refrigerator identified beverages of water and juice were set up on two separate trays to be distributed for lunch. […]

• No harm, potential for more than minimal, isolatedF554Jul 2, 2026

  Based on observations, review of the clinical record, review of facility policy/procedures and interviews for 1 of 3 sampled residents (Resident #69) reviewed for medication self-administration, the facility failed to ensure Resident #69 was assessed and clinically appropriate for self-administration of medication after a significant change and failed to ensure self-administrated medications were stored properly. The findings include:Resident #69 was admitted to the facility with diagnoses that included Parkinson's disease, dementia with psychotic disturbances, recurrent major depressive disorder with psychotic symptoms and anxiety disorder. The self-administration of medication assessment dated [DATE] at 3:56 PM identified Resident #69 was able to self-administer some medications. […]