Deer Meadows Rehabilitation Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that

the facility failed to develop a person-centered comprehensive care plan related to dementia care and/or activities for one of 35 residents reviewed (Resident Resident R55).Findings include:Review of facility policy, Care Planning Process and Care Conference dated revised on March 19, 2025, revealed The resident/patient centered care plan development will include the following interdisciplinary team members: Resident Nurse Assessment Coordinator/ Clinical Reimbursement Coordinator (RNAC/CRC), Nursing, Rehabilitation, Dietician, Food Service staff member, social worker, nursing assistant, physician(if applicable), Activities, resident and resident representative. Further review revealed Procedure: Include such initial needs/problems such as ADL's, falls, skin tears, risk for skin breakdown, nutritional status, behaviors, pacemakers, anticoagulants, psychotropic medication use, etc. Include a care plan related to the resident's primary diagnosis. Review of Resident Resident R55's clinical record revealed resident admitted to facility on July 30, 2025, with a diagnosis of Acute Kidney Failure, and Dementia (progressive degenerative disease of the brain).Review of Resident Resident R55's Quarterly MDS (Minimum Data Set- a mandatory periodic resident assessment tool) dated August 6, 2025, revealed that resident has BIMS (Brief Interview for Mental Status) of 6, indicating that resident has a severe cognitive impairment. Observation of Resident Resident R55 on September 29, 2025 at 11:35pm, revealed resident sitting alone in chair, in front of television. Observation of Resident Resident R55 on September 29, 2025 at 1:35pm, revealed resident sitting alone in chair, in front of television. Observation of Resident Resident R55 on September 30, 2025 at 12:30pm, revealed resident sitting alone

in chair, in front of television. Interview with Employee E13, Nursing Assistant on September 30, 2025 at 1:20pm, revealed that there isn't a lot for [Resident Resident R55] to engage and participate in. No activities on a 1:1 basis. [Resident Resident R55] regularly sits close to nursing station in front of television.Review of Resident Resident R55's comprehensive care plan, last revised September 26, 2025, revealed no evidence of care plan in place for dementia care or activities. Interview on September 30, 2025, at 2:20 p.m. Employee E2, Director of Nursing, confirmed that no care plan was developed for Resident Resident R55 related to his Dementia Care and/or activities. 28 Pa Code 211.10(d) Resident care policies28 Pa Code 211.12(d)(5) Nursing services

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Deer Meadows Rehabilitation Center

8301 Roosevelt Boulevard Philadelphia, PA 19152

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679

Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility policy, observation, and staff interviews, it was determined that the facility failed to provide

an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for two of eight ([NAME] 2 nursing unit and W1B nursing unit).Findings include:Based on the facility policy titled, Activity Manual last revised on April 2025 revealed Activity program are designed to meet the interest of and support the physical , mental and psychosocial well-being of each resident.During a review of activity calendar on September 29, 2025, at 11:00 a.m. the following activities were scheduled for the Skilled Nursing and Rehab nursing unit:11:00 a.m. Concentration Puzzle -GA1:00 p.m. Room visit2:00 p.m. BingoObservations on September 29, 2025, between 11:35 a.m. and 1:35 p.m., on the W1B nursing unit revealed that Resident Resident R3 was sitting in a wheelchair in front of the TV in the main area.During a review of activity calendar on September 29, 2025, at 1:00 p.m. the following activities were scheduled for the [NAME] 2 nursing unit: 1:15 p.m.- 1:1 room visit 2:00 p.m.- Bingo

Observations on September 29, 2025, between 1:15 p.m. and 1:29 p.m. did not show any room visits being conducted on the [NAME] 2 floor. The dining room contained approximately 16 residents seated with two staff members supervising them; no activities were observed.At 1:31 p.m. on the same day, an interview was conducted with the Director of Activities, Employee E15, and the Assistant Activities Director, Employee E16. Both reported that one-on-one room visits were not taking place due to staffing issues and that they were working to address the situation.Observations on September 30, 2025, at 12:30 p.m., on the W1B nursing unit revealed that Resident Resident R3 was sitting in a wheelchair in front of the TV in the main area.An interview was conducted with a nursing aide, Employee E17, on September 30, 2025, at 1:20 p.m.,

after observing Resident Resident R3 sitting in front of the TV. Employee E17 reported that the facility does not provide many activities and noted that Resident Resident R3 spends most of the time sitting in front of the TV.On October 1, 2025, at 12:37 p.m. and 1:56 p.m. Resident Resident R7 was sitting and eating on TV. When Resident Resident R3 was interviewed she reported that she also likes to color and listen to music.A review of clinical documentation for Resident Resident R19 revealed that she was admitted to the facility on [DATE REDACTED], with diagnoses of dementia (progressive disease of the brain), muscle weakness, dysphagia, and anemia. A review of the Activity Task records for the past 30 days showed that each day was marked as not applicable. There was no documentation indicating that any one-on-one activities were performed with Resident Resident R3.During a

review of activity calendar on October 1, 2025, at 1:32 p.m. the following activities were scheduled for the [NAME] 2 nursing unit: 1:30 p.m.- Gather and Go 2:00 p.m.- Busy hands Club3:00 p.m. - Remember whenOn October 1, 2025, at 1:32 p.m., an interview was conducted with an activity aide, Employee E17, who reported that Gather and Go is an activity designed to gather residents who want to participate in a group activity at 2:00 p.m. However, at the time of observation, all residents were in the dining room, and

the activity aide had only three fidget items available for approximately 15 residents. When asked if more fidgets were available, Employee E17 stated no, but noted that there were some pool noodles. She checked

the activity closet and confirmed that there were not enough fidgets to conduct a Busy Hands activity.On October 1, 2025, at 1:45 p.m., an interview was conducted with Employee E15, who reported that the facility does have more than three fidgets; however, they are spread across all eight units. The items need to be gathered in order to be made available to residents in the [NAME] 2 unit.28 Pa. Code: 201.18 (b)(3)e(2) Management

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet