Every finding on record at Stevens Park Health and Rehabilitation

Based on observations, staff interviews, review of the manufacturer's guidelines, and review of the facility policy titled Cleaning and Sanitizing, the facility failed to store stacked pans free from wet nesting to prevent bacteria, and failed to properly demonstrate the usage of the three-compartment sink to prevent foodborne illness. The facility census was 40, and all residents were receiving an oral diet.Findings include: Review of the facility policy titled Cleaning and Sanitizing revealed that all smallware equipment should be stored in a self-draining position that allows it to air dry.Review of the facility policy titled Cleaning and Sanitizing revealed that the manufacturer's guidelines for the three-compartment sink should be followed. Items should be fully submerged in the sanitizer solution per manufacturer guidelines.Review of Product Specification Document for Multi Quat Sanitizer revealed expose all surfaces to the sanitizing solution for a period of not less than 1 minute. Allow equipment to drain thoroughly and air dry.1. Observation on 9/12/2025 at 8:10 am of the dish room revealed a store rack with stacks of steam table pans. A stack of three small square steam table pans was pulled apart, and the inside of the top and middle pans had moisture.During an interview on 9/12/2025 at 8:47 am, the Certified Dietary Manager (CDM) verified that the inside of the two small steam pans were stacked and stored with moisture inside. The CDM revealed that she expects dietary staff to stack and store pans after they are dry inside. 2. Observation on 9/13/2025 at 11:50 am of Dietary [NAME] AA using the three-compartment sink to wash and sanitize the food processor bowl and lid revealed he washed the dishware items with soapy water. Dietary [NAME] AA then rinsed the items with water, placed the food processor bowl in the sanitizing solution for four seconds, placed it on the drying rack, placed the food processor lid in the sanitizing solution for two seconds, then placed it on the drying rack. Continued observation revealed that Dietary [NAME] AA re-washed and sanitized the food processor bowl and lid, and placed it on a drying rack. Dietary [NAME] AA then took three pieces of paper towel and dried the inside of the food processor bowl and lid. Further observation revealed that the facility was using a quaternary sanitizing chemical for sanitizing in the three-compartment sink. There was a poster hung on the wall above the three-compartment sink that stated, towel free zone, air dry only, no wet nesting.During an interview on 9/13/2025 at 11:50 am, Dietary [NAME] AA confirmed that the food processor bowl and lid were not placed in the sanitizing solution for one minute. Dietary [NAME] AA revealed that he did not have the dishware in the sanitary solution for one minute because he forgot. The dietary cook also confirmed that he dried the dishware items with a paper towel to speed up the drying process. Dietary Aide AA confirmed that there were posters around the three-compartment sink to provide guidance on the proper procedure, and he did not follow them.During an interview on 9/13/2025 at 11:55 am, the CDM revealed that she expected dietary staff to follow proper procedure when washing dishware in the three-compartment sink and expected staff to place dishware in sanitizing solution for at least one minute. Continued interview with the CDM revealed that dietary staff should air-dry dishware sanitized in the three-compartment sink and not use paper towels to dry.

Based on medical record review, staff interviews, and review of the facility policy titled Patient's Plan of Care, the facility failed to develop a comprehensive, person-centered care plan for diuretic use for one resident (R21) of 23 residents receiving a diuretic. This deficient practice had the potential to place R21 at increased risk of medical complications and a diminished quality of life. Findings included:Review of the facility policy titled Patient's Plan of Care, reviewed 12/27/2024, revealed that each resident should have a comprehensive, person-centered care plan designed to address their medical, physical, mental, and psychosocial needs. A further review revealed that the resident's care plan was to be updated as clinical assessments changed over time.Review of the Quarterly Minimum Data Set (MDS) assessment for R21, dated 7/8/2025, revealed Section N (Medications) documented the resident received a diuretic in the seven-day lookback period.Review of R21's care plan revealed that no care plan had been developed for the resident's use of diuretics.Review of the physician's orders for R21, revealed an order dated 12/23/2024 for furosemide 20 milligrams (mg) [a diuretic medication] to be taken orally once per day.During an interview with the Minimum Data Set (MDS) Coordinator on 9/13/2025 at 2:56 pm, she explained that she was responsible for updating and developing resident care plans based on their diagnoses, changes in care, and MDS assessments. She acknowledged that a care plan had not been developed for R21's use of diuretics, attributing this to an oversight.During an interview with the Director of Nursing (DON) on 9/13/2025 at 3:10 pm, she stated that she expected the MDS Coordinator to develop and update care plans for every resident in the facility.

Based on observations, interviews, and review of facility policies Storage Areas and Personal Appearance and Conduct revealed that the facility failed to label, and date opened food items in the walk-in refrigerator and failed to ensure dietary staff wore a hair net in the kitchen during food preparation and meal service to prevent food contamination. This deficient practice had the potential to effect 37 of 38 residents receiving an oral diet. Findings include: Review of the undated facility policy titled Storage Areas revealed - Items will be covered, sealed, labeled, and dated appropriately. Review of the undated facility policy titled Personal Appearance and Conduct revealed - Hair restraints, a hairnet and/or beard restraint will be worn while in the food prep, production, and servicing areas. Observation on 6/18/22 at 8:20 a.m. of the walk-in refrigerator revealed a package of sliced deli turkey meat was opened, wrapped with no open date. Continued observation revealed a square metal pan with cut lemon wedges, covered with no label or date. Also, a one-gallon container of Buttermilk Ranch Dressing was opened with no open date. Observation on 6/18/22 at 11:45 a.m. of the Certified Dietary Manager (CDM) in the kitchen preparing puree foods items for lunch meal revealed she was not wearing a hair net. Observation on 6/18/22 at 12:30 p.m. of the CDM revealed she was assisting with serving resident lunch meal and was not wearing hair net. During an interview on 6/18/22 at 8:25 a.m. the CDM confirmed the package of sliced deli turkey meat, lemon wedges, and Buttermilk Ranch Dressing did not have a label or open date. Continued interview with the CDM revealed she expects dietary staff to label and date food items after opening. During an interview on 6/18/22 at 2:30 p.m. the CDM revealed that she did not realize that her hair was not covered with a hair net. The CDM stated that she had put a hair net on when she arrived, and it must have fallen off. Continued interview with the CDM revealed she expects staff and even herself to wear a hair net while in the kitchen.

Based on observation, medical record review and staff interview, the facility failed to ensure that one resident (R#33) of three residents with a urinary catheter was handled in a sanitary manner to prevent the spread of infection. Findings include: Observation on 9/9/19 at 2:22 p.m. revealed that resident (R) #33 was out of bed in a wheelchair and the catheter tubing was lying on the floor. The urine in the tubing was observed to be cloudy. Record reveiw for R#33 revealed the following Diagnoses: [REDACTED]. A review of the Physician order [REDACTED]. A review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] documented that the resident had a catheter in the seven-day look-back period. The Quarterly MDS also documented that the resident had a urinary tract infection in the 30-day look back period. A review of the care plan revealed that R#33 had a urinary catheter related to an indwelling/suprapubic catheter. An observation on 9/11/19 at 7:41 a.m. revealed that the resident was lying in bed and the catheter tubing was lying on the floor. The urine in the tubing was very cloudy. An observation on 9/12/19 at 10:19 a.m. of the resident revealed that the resident was in bed and the catheter tubing was lying on the floor. An observation and interview on 9/12/19 at 11:46 a.m. with the Director of Nursing confirmed that the tubing for the catheter was on the floor and that this was an infection control issue.

Based on observation, staff interview, four week cycle menu review and policy review, the facility failed to serve the proper portion size of three (3) ounce Swiss Steak with gravy per the cycle menu for one lunch meal. This deficient practice affected 16 of 38 residents who received the Swiss Steak with gravy meal choice. Findings include: Review of the weekly menu cycle week four day two for lunch on 7/24/18 revealed resident's receiving a regular diet were to receive three ounces of Swiss Steak with gravy. Review of the facility policy titled Menus updated (MONTH) (YEAR), states it is the intent of this center to provide meals based on a menu following established national guidelines. Under procedural guidelines number five: Menu items will be nutritionally adequate, attractively served, palatable and at a safe and appetizing temperature, and within cost or budget projections. On 7/24/18 at 12:54 p.m., observation of Dietary Aide CC, plating trays for residents eating lunch in the dining room, revealed she placed a small single beef patty, which were the size of a small sausage patty, on the plates and sent them out for residents eating lunch in the dining room. She was asked to weigh the single beef patty. Using the facilities digital scale, the cooked single patty weighed 1.93 ounces. Interview on 7/24/18 at 12:54 p.m., with Regional Dietician (RD), stated the beef patties used for this meal service were four ounce frozen patties. Interview on 7/24/18 at 1:50 p.m., with RD, stated she verified with food vendor that the four ounce frozen beef patties should be cooked down to three ounces. Review of product label revealed Beef Steaks were four ounce frozen patties. Observation on 7/24/18 at 2:04 p.m., of the RD obtaining a frozen beef patty from freezer. Using facilities calibrated digital scale, she weighed the frozen patty and it weighed 4.8 ounces; she then weighted the same patty thawed and it weighed 4.25 ounces. She placed the thawed patty on the grill and cooked it. The cooked weight of the patty was 1.88 ounces; she then placed one ounce of gravy on top of the cooked patty, and the weight was 2.17 ounces.

Based on observation, record review, policy review and staff interviews, the facility failed to maintain the holding temperature of three hot foods on the steam table above 135 degrees, to prevent the potential for food-borne illnesses. There were 38 residents who received an oral diet. The sample size was 20. Findings include: Observation on 7/24/18 at 11:30 a.m., revealed sterno canisters and steam trays sitting on top of steam table. Dietary Manager (DM) stated the steam table wasn't heating on the right and left steam wells. She stated the middle well is the only one working at the moment. She further stated that it quit working yesterday afternoon. During observation of steam table temps on 7/24/18 at 12:54 p.m., obtained by Regional Dietary Manager (RDM) with the facility's calibrated thermometer, temperatures were below 135 degrees Fahrenheit (F) for broccoli, which was 110 degrees Fahrenheit (F). The chopped beef patty temperature at 12:56 p.m. was 110 degrees F and the single beef patty temperature was 110 degrees F at 12:56 p.m. The food item temperatures were verified with the RDM. The RDM removed the three food items from the tray line and placed them in oven to reheat to 165 degrees F. Observation on 7/24/18 at 1:16 p.m., steam table temperatures were rechecked for the three items by the RDM. The broccoli temperature rechecked to be at 195 degrees F, the chopped beef patty temperature rechecked to be at 181 degrees F and the single beef patty temperature rechecked to be at 191 degrees F. Review of the Hot/Cold Temperature Log dated 7/24/18 for lunch service, revealed out of oven temperature for the Swiss Steak patty was recorded as 192 degrees F; Initial temperature at meal service was recorded as 165 degrees F; Mid meal service temperature was recorded as 165 degrees F; and End of meal service temperature was recorded as 168 degrees F. The out of oven temperature for the broccoli was recorded as 174 degrees; the Initial temperature at meal service was recorded as 151 degrees F; Mid meal service temperature was recorded as 150 degrees F; and the End meal service temperature was recorded as 150 degrees F. The out of the oven temperature for the chopped steak was recorded as 163 degrees; the Initial temperature at meal service was recorded as 158 degrees F; the Mid meal temperature was recorded as 159 degrees F; the End meal service temperature was recorded as 152 degree F. There was no time documented on the log as to what time any of these temperature readings were recorded. Review of the facility policy titled Food Preparation and Distribution reviewed and updated (MONTH) (YEAR), revealed it is the intent of the facility to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices. Item number five Distribution letter b. Tray line indicates that foods will be held at or > 135 degrees F. Interview on 7/24/18 at 12:54 p.m., with RDM, stated that he expects staff to monitor the foods throughout the meal service and document on the Hot/Cold Temperature Log. If the foods drop below 135 degrees F, they are to remove the items from the tray line and reheat to 165 degrees. Once the 165 degrees has been maintained for 15 seconds, the food items are placed back on the tray line, and staff are to continue to monitor the temperatures until the completion of the meal service.

Based on observation, staff interview and review of facility policy, the facility failed to wash or sanitize hands prior to obtaining a fingerstick blood sugar for one resident (R#24) out of a sample size of 20. Findings include: Observation on 7/25/18 at 4:02 p.m. of a finger-stick blood sugar with Licensed Practical Nurse (LPN) FF revealed that she pushed R#24 down the hall in his wheelchair to his room while she pulled her medicine cart behind her down the hallway. After parking the resident in his room and parking the medicine cart in front of the resident's doorway, she donned her gloves without washing or sanitizing her hands and placed the glucose monitor on a tray along with an alcohol wipe, cotton ball and blood sugar strips. Without removing her gloves, she carried the tray in the room and sat it on the resident's bedside table, pricked the resident's finger and obtained his blood sugar. With the same gloves on she then carried the tray out of the room and sat the tray on the medicine cart. She then removed disposable items from the tray, removed her gloves and sanitized the glucose monitor and then her hands. Interview on 7/25/18 at 4:07 p.m. with LPN FF confirmed that she did not sanitize her hands prior to donning gloves and after handling the resident's wheelchair. Interview on 7/25/18 at 4:28 p.m. with the Director of Nursing revealed that she would expect the nurse to sanitize her hands prior to donning gloves to obtain a fingerstick blood sugar and after handling other items.

Based on observation, policy review and staff interview, the facility failed to ensure opened food items in the dry storage area were discarded according to the labeled use by date. In addition, the facility failed to maintain operating equipment in a sanitary condition. The census was 42 and the sample size was 20. Findings include: 1. During initial tour observation of the kitchen on [DATE] from 10:06 a.m. to 10:31 a.m., revealed the following items located in the dry storage area: one half used 12 ounce package of instant potatoes with a labeled use by date of [DATE]; and a opened 16 ounce bottle of chocolate syrup with a labeled us by date of [DATE]. Interview on [DATE] at 10:31 a.m., with Dietary Manager (DM) verified the two expired food products and discarded them. She stated that the staff check for dates every day and must have overlooked these two items. Review of the policy titled Storage Areas, reviewed and updated (MONTH) (YEAR), indicated the intent of this center is to store food that maintains quality and safety. Procedural guidelines number one letter a. Items will be covered, sealed, labeled and dated appropriately. 2. During initial tour observation of the kitchen on [DATE] from 10:06 a.m. to 10:31 a.m., revealed the microwave oven had dried food particles on the interior top roof and both sides. Also, the toaster glider had collected bread crumbs in the far right and left corners of the pan. These items were verified by the DM during the initial tour. Interview on [DATE] at 10:31 a.m., with DM, stated staff are to clean equipment as they use it. She stated the toaster was used this morning for breakfast, but did not know when the microwave oven was last used.

Based on observation, review of the facility policy, and staff interviews, the facility failed to label one (1) vial of Tuberculin Purified Protein Derivative (PPD) with the open date and failed to discard one (1) vial of expired Lantus 100 units/1 milliliter (mL) vial in one (1) of one (1) Medication Storage rooms and in one (1) of the three (3) Medication Carts. Findings include: 1. Observation of the Medication refrigerator on [DATE] at 7:35 a.m. with the Director of Nursing (DON) revealed that one (1) vial of Tubersol Tuberculin Purified Protein Derivative (PPD) dose 0.5 TU/0.1mL, vial was observed opened, with no open date labeled. The DON revealed that when the Tuberculin PPD is opened it is supposed to be labeled with the open date at the time it is opened. The DON confirmed that there was no open date labeled for the Tuberculin PPD. Review of the facilities Injectable Medication Procedural Guidelines Policy revealed that, the date opened and the initials of the first person to use the vial should be recorded. On [DATE] at 07:46 a.m. Medication Cart check for the 200 Hall, with the DON, revealed one (1) vial of Lantus 100 units/1 mL vial with the opened date of [DATE] with pharmacy sticker stating that Lantus expires 28 days after being opened. The DON acknowledged that Lantus does expire twenty-eight (28) days after the open date and that this vial of Lantus was expired. Review of the calendar revealed that twenty-eight days from the opened date of [DATE] was [DATE]. On [DATE] at 9:01 a.m. interview with Eldercare Pharmacy Representative BB for the facility stated that Lantus - expires 28 days after it is opened and yes, the Lantus 100 units/1mL was one day expired. Continued interview regarding the Tuberculin PPD revealed that once Tuberculin (PPD) is opened the opened/start date should be labeled. Tuberculin (PPD) is good for one month after it is opened; however, Per BB, When I come in to the facility and if I find a Tuberculin PPD opened, with no open date labeled, then I throw it away because we have no way of knowing when it was opened.

Based on observation, record review, resident and staff interview, the facility failed to post a notice of the availability of the State survey results for two (2) of four (4) days of the survey. The facility census was forty-eight (48) residents. Findings include: Review of the 2015 monthly Resident Council Minutes from January to September revealed that there was no documentation that the residents in the meeting were informed that they had the ability to review the State survey results, nor where the results were located. During multiple observations in the facility on 10/26/15 and10/27/15, revealed that the survey results were not found, nor was a sign found posted to indicate the availability and location of the results. During interview with the Administrator on 10/28/15 at 1:28 p.m., he verified that there was no sign posted announcing the location of the survey results anywhere in the building. During observation at this time, he obtained a brownish-tan colored notebook labeled on the spine with a white sticker with half-inch tall print labeled Licensure Results, that was inside a horizontal file holder on a desk in the hallway near the main entrance. Interviews were done with three residents who were active in the Resident Council, all of whom were coded as being cognitively intact on their most recent Minimum Data Set (MDS). During interview with resident R on 10/28/15 at 1:28 p.m., she stated that she did not know that she had the ability to review the survey results, and did not know where they were located. During interview with resident S on 10/29/15 at 9:01 a.m., she stated that she did not ever recall staff discussing the availability of the survey results in the Resident Council meetings, and she did not know she had the ability to review them. During interview with resident T on 10/29/15 at 10:32 a.m., she did not recall anyone ever mentioning that she had the ability to review the results of the State survey inspections, did not know where the results were located, and that she would be interested in reviewing them.

Based on observation, record review and staff interview the facility failed to follow the menu related to portion size of the entree for lunch for ten (10) of twenty-one (21) residents who ate their meals in their rooms. Findings include: During observation of the lunch meal on 7/11/12 at 11:50 a.m. the dietary staff (DS) identified the scope she was using as a # 8 scoop. The DS was observed serving the turkey casserole entree with this scoop. The surveyor observed five regular diet entrees plated by this dietary staff person. Review of the current menu cycle for lunch on 7/11/12 revealed that the serving size for the turkey casserole should be 8 ounces. The documentation of the diet spreadsheet for 7/11/12 revealed that a # 8 scoop was 4 to 5 ounces and residents should have received two (2) scoops of the turkey casserole to meet the 8 ounce requirement. Interview with the Dietary Manager and the DS on 7/11/12 at 12:10 p.m. revealed that they were serving only one scoop of the entree which would measure out as only four to five ounces instead of the 8 ounces as directed on the approved pre-planned menu. Interview with the Dietary Manager on 7/11/12 at 12:25 p.m. revealed that 10 resident trays had been delivered with the incorrect amount of turkey casserole, however the remaining 11 trays served had the correct amount of turkey casserole entree.

Based on observation, record reviews and staff interviews, the facility failed to ensure that two (2) residents (#5, and 37) on a sample of nineteen (19 ) residents received necessary treatments according to the physician's orders to treat pressure sores. Findings include: 1. Review of the admission Minimal Data Set assessment dated [DATE] assessed resident #37 as having two unstageable pressure sores with suspected deep tissue injury. Review of the admission physician's orders dated 12/17/10 revealed the resident was to have wet to dry gauze dressings to the right heel daily. This treatment order continued until 1/26/11. Review of treatment record for December 2010 thru January 25, 2010 revealed the wet to dry dressings were discontinued and to observe the right heel blister, however there was no physician's order in the record to discontinue the wet to dry dressing or to just observe the blister to the right heel. Review of the nursing assessment dated [DATE] revealed that the resident had a blister to the right heel with serous drainage on the dressing when removed and this blister had a small opening. An achilles blister was intact. Review of the Treatment Record-Wound assessment dated [DATE] revealed the right heel measured 7 x 11.3 x 0 and was an unstageable deep tissue injury with light drainage. The last measurement on the right heel done 1/26/10 and measured 3.7 x 4.3 x 0 centimeters in size and was unstageable with no drainage. Observation of the wound care treatment done on 2/2/11 at 8:15 am revealed that the right heel had black eschar. Interview with the Registered Nurse Consultant on 2/1/11 at 9:20 am revealed that the area on the resident's heel was a closed blister and the facility follows their wound protocol for a blister, which was to just observe the blister, until it opens. She further indicated that the admission nurse forgot to write the physician's order to discontinue the wet to dry dressing and just observe the blister. 2. Record review for resident #5 revealed the resident was admitted to the facility on [DATE] after a fall and surgical repair of the left hip. The Foot and Skin Assessment sections of the Nursing Admission assessment dated [DATE] noted a 7.0 centimeter (cm) long by 0.8 cm wide area on top side of left foot, and a 3.5 cm by 1.0 cm area on the outer aspect of the left foot. The area across the left foot was described as having an open yellow base with non-approximated edges. Review of physician's orders from 12/16/10 thru 01/26/11 revealed the dressing for the left foot was to be changed every three days and as needed. Review of the resident's Treatment Records revealed that there was no evidence that the dressing to the left foot was changed between 12/19/10 and 12/24/10; between 12/27/10 and12/31/10; between 12/31/10 and 01/05/11; between 01/12/11 and 01/17/11 and between 01/22/11and 01/26/11. Additionally, there was a notation on the Treatment Record of 'OTA' on 01/14/11 when the dressing was due to be changed. Interview conducted 02/03/11 at 8:30 a.m.with the Wound Care Coordinator Licensed Practical Nurse (LPN) 'AA' revealed that the facility believed the wound on the resident's left foot was caused from compression hose or a protective boot that was too tight when she was in the hospital. "AA" further revealed that the facility nurse assigned to the resident did the ordered dressing changes, as well as weekly skin assessments. She indicated that she observed all the wounds weekly on Wednesdays to measure and assess if the wound was healing, and/or if the wound care consultant needed to be contacted for suggestions. LPN 'AA' revealed that she saw resident #5's foot for the first time on 01/05/11, and verified that the description of the wound on the Admission Assessment was that of an open wound with a yellow base, but stated when she first saw it in January it looked like a line surrounding the entire foot that was purplish,and red in color. She felt like it was deep tissue injury (DTI). She verified there was no evidence that the dressing was changed as ordered on [DATE]; between 01/01/11-01/05/11; and when due on 01/25/11, and she did not know why the dressing was not changed. She thought the abbreviation 'OTA' on the Treatment Record meant the resident was not in the building, but could find no documentation in the nurse's notes to support this. During interview on 02/03/11 at 10:45 a.m. with the Director of Nurses (DON), she indicated that 'OTA' generally meant the resident was out to an appointment, but that the dressing on the left foot should have been changed when the resident returned to the facility.

Based on observation, record review, and staff interview, the facility failed to administer the amount of enteral nutrition according to the physician's orders [REDACTED]. Findings include: Observation conducted 02/02/11 at 8:25 a.m., revealed Licensed Practical Nurse (LPN) 'AA' administered the morning medications to resident #175 via the resident's gastrostomy tube. "AA" also gave one 8-ounce/237 milliliters (ml) can of Glucerna 1.2, which was scheduled to be given at that time. Review of resident #175's clinical record revealed a physician order [REDACTED]. of Glucerna 1.2 every 4 hours. During interview on 02/02/11 at 10:15 a.m., LPN 'AA' acknowledge that the label on a can of Glucerna indicated that the 8 ounces was equal to 237 mL. She verified that the physician's orders [REDACTED].