Module 6: Long Term Care & Pediatrics
Oak ridge rehabilitation and healthcare center
Oak Ridge Rehabilitation & Healthcare Center, located in Taylor, Pennsylvania, is one such facility that specializes in skilled nursing, long-term care, and a range of rehabilitation services designed to support recovery and promote well-being in a warm, engaging environment. Oak Ridge emphasizes personal dignity and community engagement while delivering care tailored to each resident’s needs. i was lucky to have my long term rotation in this Facility with my Preceptor Desiree Saar, she is Knowledgeable, informative and nice to deal with.
The center offers a wide range of services, including skilled nursing care, personalized long-term care, and full service rehabilitation programs designed to help residents regain strength, mobility, and independence. Their rehabilitation services encompass physical therapy, occupational therapy, speech therapy, orthopedic, cardiac, and stroke rehabilitation, using evidence-based treatments and state of the art equipment to support recovery. The facility emphasizes a compassionate, family-like atmosphere, where care plans are tailored to meet each resident’s medical needs and personal goals, and staff strive to promote dignity, comfort, and overall well-being.
State Inspection
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During my long-term care rotation, I had the opportunity to observe the importance of institutional state inspections in ensuring regulatory compliance and resident safety. At Oak Ridge Rehabilitation & Healthcare Center, the Pennsylvania Department of Health conducted an abbreviated complaint survey and state revisit, as documented in the official letter dated October 27, 2025. The inspection evaluated whether the facility met federal certification standards and state licensure requirements, referencing Title 42 CFR Part 483 and the 28 PA Code.
This experience demonstrated how state inspections maintain quality of care, enforce accountability, and strengthen facility policies to protect residents’ health and well-being.
MDS, CAT, & CAA
The Minimum Data Set (MDS) is a Long Term Care screening/ assessment tool used in facilities that participate in Medicare or Medicaid. Throughout my rotation I became very familiar with this form. During my days at Oak Ridge Rehabilitation and Health Care Center, I completed admission, quarterly, and annual MDS forms. The corresponding documentation included either admission assessments (admission MDS), progress notes (quarterly MDS), or annual assessments (annual MDS). My preceptor walked me through how to complete Care Area Assessments (CAA). This helped further investigations of nutrition-related Care Area Triggers (CAT), which would trigger in the annual MDS. CTAs care area triggers are specific resident responses for one or more MDS elements. The triggers help identify residents who are at risk for developing certain functional issues that may need further assessment. CAAs helped determine if interventions and care planning were needed for the patient. Below are examples of MDS admission assessments.
I added PES statement to the attached examples.
5 Quarterly Assesment
During my long-term care rotation at Oak Ridge Rehabilitation and Healthcare Center, I completed multiple MDS (Minimum Data Set) quarterly assessment forms as part of my dietetic internship responsibilities. Over the course of the rotation, I independently conducted more than five full quarterly assessments, and I uploaded six completed forms that included detailed PES statements for each resident. These assessments allowed me to evaluate residents’ nutritional status, weight changes, intake patterns, and risk factors, and to document individualized nutrition diagnoses and interventions. Completing these MDS quarterly forms strengthened my clinical judgment, enhanced my understanding of regulatory documentation requirements, and improved my ability to integrate nutrition care into the interdisciplinary care planning process.
Follow Up and Reassessment Documentation
To complete follow-up and reassessment documentation, I collaborated with Desiree, the Registered Dietitian, to review patient records and monitor weight changes. We compared data at 1, 3, and 6-month intervals, highlighting any significant percentage fluctuations. For patients on the weekly weight monitoring list, we tracked trends to identify abnormal variations. When several residents showed sudden increases or decreases, we discovered that the scale on that floor required calibration. In another case, we requested a physician referral for a patient who experienced a notable weight gain, likely related to edema or fluid retention given his medical history. Conversely, some residents’ weight loss was attributed to decreased appetite. This process reinforced the importance of accurate measurements and interdisciplinary communication in patient care
I am attaching the documents for a patient I had the opportunity to work with. The patient experienced significant weight loss, approximately 22 lbs in one month, and presented with poor appetite. To address his increased nutritional needs, we adjusted his care plan by adding an additional protein supplement to help ensure he was meeting his daily requirements.
Medical and skin care rounds
I had the opportunity to attend wound care rounds with the Assistant Director of Nursing ADON with the wound care nurse at Oak Ridge Rehabilitation and Health Care Center on 11/17/2025. I observed the team make rounds throughout the building to patients who are being followed for wounds. Wounds are rounded on each Thursday and every week. I saw a variety of wounds, including, but not limited to, pressure ulcers, vascular wounds, and Venous/Arterial ulcers. And I had the chance to watch the Dietitian update and add her recommendations.
Adaptive Eating Devices with OTR
During my rotation at Oak Ridge Rehabilitation and Healthcare Center, my preceptor arranged for me to shadow the occupational therapist (OT). The OT reviewed adaptive eating devices with me and emphasized the importance of strong communication between OT, Speech-Language Pathology, and the RD to help patients maintain weight, ensure adequate intake, and remain as independent as possible during meals. I observed the use of a Kennedy Cup, a lipped plate to reduce spillage, and weighted utensils for patients with tremors. Other adaptive tools included double-handled cups, Provale cups, suction bowls, and partition plates. This experience showed me how occupational therapy uses detailed, individualized strategies to support safe and effective eating.
Menu Design & Modification
Always Available Menu
During my rotation at Oak Ridge Rehabilitation and Healthcare Center, I had the opportunity to observe several diet plans, including controlled carbohydrate, dental soft, soft bite-size, minced and moist, pureed, and no-added-salt diets. I also witnessed how patients progressed through these diets, moving from mechanical or liquid diets to regular diets, and sometimes transitioning back as needed based on their condition.
And I noticed that they have the always available menu. And I am attaching a copy.
IDT Meetings & Nutrition Care Plans
During my rotation, I participated in several interprofessional meetings that supported coordinated, patient-centered care. The daily morning meetings ensured timely communication about new admissions, discharges, weight changes, and nutrition-related updates, allowing the team to respond quickly to patient needs. The weekly Utilization Review (UR) meetings provided a deeper evaluation of special cases, insurance coverage, and the appropriateness of nutrition interventions. I also attended multiple care plan meetings, where the team reviewed individual patient progress, addressed nutrition concerns, and collaborated closely with families. Finally, the monthly quality management meeting focused on reviewing QAPI indicators, including significant weight trends and the effectiveness of current nutrition strategies. Together, these meetings strengthened interdisciplinary collaboration and supported safe, consistent, and effective nutritional care.
meal rounds, caloric intake, recommended changes
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We had a patient with a body weight of 111.8 lb and meal intake ranging from 51% to 100%. She was experiencing septic shock and had full upper dentures. Because she was not consistently consuming all of her meals, we added yogurt to each meal and offered her a chocolate shake twice daily to help ensure she met her energy needs.
Modified Barium Swallow (MBS)
During my long-term care rotation at Oak Ridge Rehabilitation and Healthcare Center, I had the opportunity on December 1, 2025, to shadow Sara, the Speech Therapist, during a swallowing evaluation for a patient who had recently begun coughing during meals. Using a standardized swallowing assessment form, we evaluated his ability to safely manage oral intake. Although I did not observe an MBS, FEES, or VFSS during my rotation, Sara reviewed sample old reports with me the following day, which deepened my understanding of how instrumental swallowing assessments are interpreted. I also referenced the facility’s manual from Module 6 to review standard food textures used for patients requiring diet modifications
Resident Referrals
During my rotation at Oak Ridge Rehabilitation and Healthcare Center, I had the opportunity to observe multiple patient referrals made as part of the interdisciplinary care process. Many of these referrals were directed to the speech-language pathologist (SLP) for swallowing assessments, while others were referred to the primary occupational therapist for functional and cognitive evaluations. One specific case involved a resident who previously ate well but recently began experiencing difficulty swallowing and reported episodes of choking. A referral was promptly made to the SLP for a swallowing evaluation, and the corresponding referral form for this patient is attached below as documentation of the process.
Adjusted weight with amputation
During my long-term care rotation, I learned that many patients with amputations need special methods to estimate BMI. Body segment proportions were studied as far back as the late 1800s and later updated, and these measurements are still used today to adjust BMI for people who are missing a limb.
A common formula used is:
WtE = Wto / (1 – P)
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WtE = estimated total body weight
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Wto = current (observed) weight
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P = proportion of body weight represented by the missing limb
Example:
If a patient weighs 85 kg and has a leg amputated at the knee, the missing segment represents about 5.9% of body weight.
So: 85 kg ÷ 0.941 = 90.3 kg estimated weight, which can then be used to calculate BMI.
Extra things
Pantry check
During my long-term care rotation at Oak Ridge Rehabilitation and Healthcare Center, my preceptor conducted daily checks on the pantries across all three floors. Each inspection included verifying food storage temperatures, reviewing sanitation practices, and ensuring that all food items were properly labeled with dates and names. This routine emphasized the importance of safety, organization, and strict adherence to facility and regulatory standards in maintaining a safe nutrition environment for residents
