Immaculatemarycenter For Rehabilitation&healthcare

Based on the review of clinical records, observations, and interviews with resident representative and staff, it was revealed that the facility failed to provide appropriate services to promote and maintain hearing abilities for one of five residents reviewed. (Resident R3)Findings Include:Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide.Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide.Interview with Resident R2's representative on September 15, 2025, at 10.50 a.m. revealed that the resident had difficulty hearing and she was missing her hearing aid.

Resident R5 was not using a hearing aid when she was admitted to the facility however a week after her admission the hearing aid was missing.

Resident representative said the resident was not seen by an audiologist or the hearing aid was replaced.

Review of care plan for Resident R2 dated November 7, 2024, revealed that the resident had communication problems related to hearing loss/deafness and language barrier.

The interventions included communication device, use hearing aids.Review of clinical record revealed no evidence that the resident was seen by an audiologist or scheduled to visit an audiologist to manage hearing impairment or potentially replacing lost hearing aids.Review of an audiology consult report dated March 10, 2025, revealed that the audiology consult was cancelled and a comment was provided patient could not understand.

Italian is her main language.Interview with Director of Nursing, Employee E2, on September 15, 2025, at 2:30 p.m. confirmed that the resident was not seen by an audiologist and the resident did not have hearing aids.28 Pa.

Code 211.12 (d)(1)(3)(5) Nursing services28 Pa.

Code: 201.18 (b)(2) Management28 Pa.

Code: 211.10 (d) Resident care policies

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Immaculatemarycenter for Rehabilitation&healthcare

2990 Holme Avenue Philadelphia, PA 19136

SUMMARY STATEMENT OF DEFICIENCIES

nutritional or pharmacological interventions to control the elevated blood sugar.

Review of the clinical record revealed that podiatry recommendations for optimal diabetic management dated August 7, 14, and 21, were not addressed by the physician, and the resident demonstrated elevated blood sugar levels during most checks.

Review of the clinical record for Resident R1 dated August 29, 2025, revealed that the resident was sent to the emergency department from a doctor's appointment for wound infection.Review of the clinical record for Resident R1 dated August 29, 2025, revealed that the resident was admitted to the hospital with osteomyelitis (an infection of the bone).Interview with the Director of Nursing on September 15, 2025, at 2:30 p.m. confirmed that the podiatry recommendations for diabetic management for Resident R1 to promote wound healing were not addressed by the physician.28 Pa.

Code 211.12(d)(1)(2)(5) Nursing services

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Immaculatemarycenter for Rehabilitation&healthcare

2990 Holme Avenue Philadelphia, PA 19136

SUMMARY STATEMENT OF DEFICIENCIES

Provide and implement an infection prevention and control program.

Findings Include:Review of facility policy Enhanced Barrier Precautions dated September 2024 revealed that Enhanced barrier precautions (EBP) utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of MDRO's(Multi drug Resistant organisms).

Examples of high contact resident care activities requiring gown and gloves for EBP include but are not limited to Dressing, Wound care: any skin opening requiring a dressing.According to CDC (Centers for Disease Control and Prevention) guidelines Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings revealed that Wound care supplies such as dressing materials and equipment should be selected and gathered prior to entering the patient/resident care area to avoid accessing the supply cart/clean storage area during the procedure.

Only the materials needed for an individual patient/resident should be brought into the patient/resident's room or treatment area and placed on a clean surface and away from potential sources of contamination (e.g., away from splash zones of sinks) prior to beginning wound care activities.

Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or the patient's immediate environment, After contact with blood, body fluids or contaminated surfaces, Immediately after glove removalObservation of Resident R5's room on September 15, 2025, at 10.00 a.m. revealed that the resident was sitting in a wheelchair.

Employee E4, Licensed Practical Nurse and Employee E5, Nurse Aide was observed doing wound care.

Both employees were not wearing a gown and gloves. It was observed on the resident door a sign of EBP.

Interview with Licensed nurse, Employee E3, on February 24, 2023, at 10:00 a.m., confirmed that Employee E4, and Employee E5 did not wear appropriate personal protective equipment while providing wound care for Resident R5.A wound care observation of Resident R4 on September 16, 2025, at 11:00 a.m. with Licensed nurse, Employee E6, revealed the employee placed the dressing supplies including gloves, gauze, saline bottle, border dressing and wound care medication on resident's bed at the foot of the bed. It was observed that the employee wore clean gloves, removed old dressing and wound was cleaned with saline, it was observed that the saline was dripping from the gauze to the bed while employee was cleaning the wound.Further observation of the procedure revealed that the employee removed the worn gloves and applied new gloves from the gloves that were on the bed.

There was no hand washing after the wound was cleaned and before applying the new dressing.28 Pa.

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

Code 211.12(d)(1) Nursing services

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