Maybrook Hills Rehabilitation and Healthcare Cente

In the surveyor’s words

From the most serious findings on record at Maybrook Hills Rehabilitation and Healthcare Cente, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jan 21, 2022

  Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for eight of 23 residents reviewed (Residents 1, 3, 4, 5, 6, 7, 8, 9). […]

• Actual harm, isolatedF600Jun 9, 2022

  Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of six residents reviewed (Resident 1). Findings include: The facility's abuse policy, dated June 1, 2021, indicated that every resident has the right to be free from mistreatment, neglect, abuse, exploitation, and misappropriation of property. This is a Zero Tolerance policy and will be strictly enforced. […]

• Actual harm, isolatedF600Jul 27, 2021

  Based on review of policies, investigative reports and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and the facility's policy for transporting residents for one of six residents reviewed (Resident 1), resulting in a fracture for the resident. Findings include: The facility's policy regarding abuse prevention, dated June 1, 2021, indicated that each resident had the right to be free from mistreatment, neglect, and misappropriation of property, and no one was to subject residents to abuse, including facility staff, other residents, consultants, volunteers, other agencies serving the resident, family members, legal guardians, friends, or… […]

• No harm, potential for more than minimal, patternF636Aug 7, 2025

  Based on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for 11 of 65 residents reviewed (Residents 1, 9, 30, 39, 51, 85, 108, 115, 180, 222, 238). […]

• No harm, potential for more than minimal, patternF638Aug 7, 2025

  Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 15 of 65 residents reviewed (Residents 10, 22, 43, 71, 72, 75, 77, 83, 108, 112, 115, 124, 150, 190, 199).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more… […]