Pennsylvania Department of Health
ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are 173 surveys for this facility. Please select a date to view the survey results.

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ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to one complaint completed on June 12, 2026, it was determined that St Monica Center for Rehabilitation &; Healthcare was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:
Based on review of facility policy, review of clinical record, observations, and interview with staff, it was determined that the facility failed to review and revise one care plan related to restorative nursing program for one of 33 residents reviewed (Resident R17).

Findings Include:

Review of facility policy titled "Interdisciplinary Care Planning Protocol", dated July 2025, revealed that "Problems established by the team with resident/family input MUST be specific and individualized meaning as resident changes are noted, the resident plan of care must be revised".

Review of resident records revealed that Resident R17 was admitted to the facility on June 9, 2021, and had diagnoses including, but not limited to, atrophy (muscles decreasing in size, typically due to disuse), muscle spasms, and periodic paralysis.

Observation on June 11, 2026, at 11:17 a.m. revealed Resident R17 had multiple contractures, resulting in the inability to use or independently move any of his/her limbs, which were drawn tight into the body.

Review of the Resident R17's most recent MDS (Minimum Data Set- a periodic review of resident care needs) dated February 18, 2026, Section GG, Functional Abilities, revealed that the resident was dependent on staff for all care and mobility tasks, such as eating, transferring between the bed and the chair, and repositioning.

Review of Resident R17's care plan, last reviewed on March 9, 2026, revealed a care plan initiated on July 12, 2023, which stated the resident "may benefit from a restorative nursing program", with an intervention to "perform sit-to-stand transfer...3-5 [times per week]".

Interview with Therapy Director, employee E14, on June 12, 2026, at 12:04 p.m. revealed that Resident R17 is not safe for any type of transfer, except by mechanical lift, and has been that way for "years".

Interview on June 12, 2026, at 3:00 p.m., Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed that the care plan for Resident R17 should have been updated to reflect current status.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 07/24/2026

The submission of this response to the statement of deficiencies by the undersigned does not constitute an admission that the deficiency existed and/or required correction. This response is prepared, executed, and submitted solely as a requirement of the provisions of federal and state law.

F657
It is the practice of the facility to review and revise care plans.
-Resident R17's care plan was updated to reflect current status with transfers.
- Other residents that have the potential to be affected will have their care plans reviewed for accuracy with transfers.
- Education will be completed by DON/Designee with appropriate staff to ensure each resident has a reviewed and revised care plan.
- The DON/Designee will complete a weekly random audit (10) of residents for 1 month then audit (10) monthly to ensure the residents have a reviewed and revised care plan. Results of the audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss the need for further audits.
-To be completed by 7/24/2026.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to ensure residents were free from accident/hazards and received adequate supervision related to eating and medication administration for two of 33 residents reviewed (Resident R169 and R8).

Findings include:

Review a facility policy "Interdisciplinary Care Plan Protocol", revised July 2025, revealed that the interdisciplinary team including nursing, social services, dietary, activities, rehabilitation services, physicians, residents, and family members, is responsible for assessing resident needs and developing an individual plan of care. Review of facility policy revealed care plans should be specific to resident needs and revised as changes occur. The policy emphasizes the development and ongoing revision of individualized interventions to address identified safety risks and promote resident well-being.

Review of the Resident 169's Minimum Data Set (MDS federally mandated resident assessment and care screening) dated May 28, 2026, revealed the resident was admitted to the facility on May 22, 2026. Per the MDS, Resident R169 has severe cognitive impairment and diagnoses of multiple fractures (breaks in more than one bone, often resulting in pain, limited mobility, and impaired functional ability), dementia (a progressive cognitive disorder characterized by decline in memory, thinking, reasoning, and the ability to perform daily activities), and schizophrenia (a chronic psychiatric disorder involving disturbances in thought processes, perception, emotional responsiveness, and behavior, which may include hallucinations, delusions, and disorganized thinking).

Continued review of Resident R169's MDS revealed the resident requires maximal assistance with lower body dressing/footwear and requires partial assistance with transfers and sit-to-stand activities.

Review of Resident R169's clinical record revealed a physician order dated May 28, 2026, for Lidocaine 4% patch to the left shoulder and lower back, applied once daily for pain, for 12-hours on and 12-hours off.

Review of manufacturer labeling for Lidocaine 4% patches directs that the product be used only as directed and warns against applying additional patches beyond the recommended amount. The application of additional lidocaine patches to locations not authorized by the physician's order was inconsistent with the prescribed treatment regimen and the manufacturer's instructions for use.

Review of Resident R169's Self-Medication Assessment dated May 22, 2026, revealed that the resident was assessed as unable to self-administer medications.

Observation on June 9, 2026, the resident was noted sitting in a wheelchair with two Lidocaine 4% patches applied to both knees. One patch lacked any date, time, or staff initials. The second patch was labeled with a date of June 1, 2026, and a shift designation; the signature was illegible.

Interview on June 9, 2026, with Nurse Aide, Employee E12 confirmed Resident R169 had Lidocaine 4% patches applied to both knees and that either Resident R169 or resident representative applied the patches.

Review of Resident R169's clinical record revealed no physician order was identified authorizing the application of lidocaine patches to Resident R169's knees.

Review of the Resident R8's MDS dated May 21, 2026, revealed Resident R8 was admitted to the facility on November 29, 2024, and has diagnoses of pneumonia, dysphagia (difficulty swallowing), and sepsis. Further review of Resident R8's MDS revealed the resident requires extensive assistance with activities of daily living and requires setup and cleanup assistance with eating.

Review of the resident R8's care plan revealed that the resident was at risk for respiratory distress related to aspiration and pneumonia. Interventions dated June 5, 2026, included monitoring for signs and symptoms of respiratory distress and providing supervision and feeding assistance during meals.

Review of Resident R8's clinical record revealed an active physician order dated June 4, 2026, that Resident R8 "needs supervision/feeding assistance with meals for aspiration".

Observation on June 10, 2026, at 8:25 a.m. revealed Resident R8 was alone in his/her room with a breakfast tray placed in front of the resident. No staff members were present providing supervision or feeding assistance.

Interview on June 10, 2026, at 8:25 a.m. with Resident R8, the resident stated that staff do not typically provide supervision or assistance with meals. Resident R8 further reported a recent hospitalization secondary to treatment for aspiration pneumonia.

Subsequently interview on June 10, 2026, at 8:30 a.m. with Licensed Nurse, Employee E11, confirmed Resident R8 was having breakfast alone in his/her room. Licensed Nurse, Employee E11, reported that Resident R8 typically eats breakfast in his/her room and that staff periodically check in.

28 Pa. Code 201.18 (b)(3) Management.

28 Pa. Code 201.20(a)(1) Staff development.

28 Pa. Code 211.10 (a) Resident care policies.

28 Pa. Code 211.12 (d) 5) Nursing services.

Plan of Correction - To be completed: 07/24/2026

F689
It is the practice of the facility to ensure residents are free from accident/hazards and receive adequate supervision related to eating and medication.
-Resident 169 had the Lidocaine patches applied as per the physician order. Resident 8 is supervised and assisted as per physician order.
- Other residents that have the potential to be affected will have their physician orders reviewed to ensure they are free from accident/hazards and receive adequate supervision.
- Education will be completed by DON/Designee with appropriate staff to ensure each resident is free from accident/hazards and receive adequate supervision related to eating and medication.
- The DON/Designee will complete a weekly random audit (10) of residents for 1 month then audit (10) monthly to ensure the residents are free from accident/hazards and receive adequate supervision related to eating and medication. Results of the audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss the need for further audits.
-To be completed by 7/24/2026.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:
Based on review of facility policy, review of clinical records, observations, and interview with staff it was determined that the facility failed to ensure proper labeling of medications for one of 33 residents reviewed (Resident R175).

Findings Include:

Review of the facility policy titled, "Storage of Medication" revised July 2025, revealed drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling.

Observations of medication administration was conducted with Licensed Nurse, Employee E7, on June 11, 2026, at approximately 9:00 a.m. Observations during medication administration for Resident R175 revealed that the blister pack holding Resident R175's medication failed to include the physician orders specifying the route, frequency, and dose on the medication label. Instead "See orders" was labeled on Resident R175's medication blister pack.

Interview on June 11, 2026, at 2:00 p.m. with the Assistant Director of Nursing, Employee E3, confirmed the improper labeling of Resident R175's medication.

28 Pa Code: 201.14 (a) Responsibility of licensee.

Plan of Correction - To be completed: 07/24/2026

F761
It is the practice of the facility to ensure proper labeling of medications.
-Resident 175's medication was returned to pharmacy for proper labeling.
- Other residents that have the potential to be affected will have their medication containers reviewed for proper labeling.
- Education will be completed by DON/Designee with appropriate staff to ensure proper labeling of medications.
- The DON/Designee will complete a weekly random audit (10) of residents for 1 month then audit (10) monthly to ensure the proper labeling of medications. Results of the audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss the need for further audits.
-To be completed by 7/24/2026.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:
Based on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure complete and accurate documentation related to a Neurological Assessment Flow Sheet for one of 33 residents reviewed (Resident 187).

Findings Include:

Review of facility documentation "Neurological Assessment Flow Sheet Instructions" revealed staff should record the date and time of each assessment then proceed to document the appropriate response as follows: level of consciousness, pupil response, motor functions (hand grasps/extremities), pain response and vitals.

Per the "Neurological Assessment Flow Sheet" vital signs and neurological checks should be completed per protocol: every fifteen minutes for one hour, every thirty minutes for one hour, every hour for four hours, and then every four hours for twenty-four hours.

Review of Resident R187's neurological assessment flow sheet revealed assessments were initiated on April 25, 2026, at 4:45 p.m.

Continued review of Resident R187's neurological assessment flow sheet revealed staff failed to document pupil response and motor functions every hour for four hours, and then every four hours for twenty-four hours.

Further review of Resident R187's neurological assessment flow sheet revealed staff failed to document the remaining four neurological assessments (level of consciousness, pupil response, motor functions (hand grasps/extremities), pain response, and vitals on April 27, 2026, that were due at 11:00 a.m., 3:00 p.m., 7:00 p.m., and 11:00 p.m.

Interview on June 12, 2026, at 2:00 p.m. with the Corporate Director of Nursing, Employe E6, and Assistant Director of Nursing, Employee E3, confirmed Resident R187's neurological assessment flow sheet was incomplete.

28 Pa. Code 211.5 (f)(iv) Medical records.

Plan of Correction - To be completed: 07/24/2026

F842
It is the practice of the facility to ensure complete and accurate documentation related to a Neurological Assessment Flow Sheet.
-Resident 187 has discharged from the facility.
- Other residents that have the potential to be affected will have their Neurological Assessment Flow Sheet checked to ensure complete and accurate documentation.
- Education will be completed by DON/Designee with appropriate staff to ensure complete and accurate documentation related to a Neurological Assessment Flow Sheet.
- The DON/Designee will complete a weekly random audit (10) of residents for 1 month then audit (10) monthly to ensure complete and accurate documentation related to a Neurological Assessment Flow Sheet. Results of the audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss the need for further audits.
-To be completed by 7/24/2026.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:
Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement proper infection control practices related to enhanced barrier precautions for one of 33 residents reviewed (Resident R175).

Findings include:

Review of the facility policy titled, "Enhanced Barrier Precautions (EBP)" dated April 2024, revealed the facility implements effective measures to prevent the transmission of Multi-Drug-Resistant Organisms (MDROs). EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) by utilizing a gown and gloves during high contact resident care activities. EBP is employed when performing device care or use.

Review of Resident R175's care plan dated April 17, 2025, revealed the resident was on Enhanced Barrier Precautions (EBP) due to a wound. Interventions include EBP signage posted outside the resident's room and implement EBP as ordered.

Observation of medication administration on June 11, 2026, at approximately 9:00 a.m. revealed Licensed Practical Nurse (LPN), Employee E7, failed to put on a gown when obtaining blood sugar levels for Resident R175.

Interview on June 11, 2026, at 2:00 p.m. with Assistant Director of Nursing/Infection Preventionist, Employee E3, confirmed LPN, Employee E7, failed to implement proper PPE related to EBP for Resident R175.

28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 211.12 (d)(5) Nursing services.

Plan of Correction - To be completed: 07/24/2026

F880
It is the practice of the facility to implement proper infection control practices related to enhanced barrier precautions.
-Resident 175's enhanced barrier precautions are followed by staff.
- Other residents that have the potential to be affected will have proper infection control practices followed as related to enhanced barrier precautions.
- Education will be completed by DON/Designee with appropriate staff to ensure proper infection control practices are followed related to enhanced barrier precautions.
- The DON/Designee will complete a weekly random audit (10) of residents for 1 month then audit (10) monthly to ensure proper infection control practices are followed related to enhanced barrier precautions. Results of the audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss the need for further audits.
-To be completed by 7/24/2026.

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