Renaissance Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 4712 Chester Avenue, Philadelphia, Pennsylvania 19143
- CMS Provider Number
- 395628
- Inspections on file
- 21
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Renaissance Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not notify the Office of the State LTC Ombudsman of emergency transfers and discharges for nine months. This was due to a new social worker's oversight, as confirmed by the Nursing Home Administrator. Specific cases included a resident transferred with pneumonia and another hospital transfer, both lacking ombudsman notification.
The facility did not ensure residents could file grievances anonymously, as grievance forms were only available in the social services office, requiring direct requests to the Director of Social Services. No locked grievance boxes were present on the first and second floors, and many residents were unaware of how to access grievance forms.
The facility failed to honor dietary preferences for three residents, leading to dissatisfaction and inappropriate meal service. A resident repeatedly informed staff of his dislike for certain foods but was served them anyway. Another resident on a no-salt diet found the food too salty and was offered alternatives that did not align with his preferences. Additionally, a third resident did not receive the meal items listed on her meal ticket. Interviews revealed that kitchen staff were unable to access residents' documented dislikes, leading to inappropriate meal substitutions.
The facility did not provide meals at appropriate times for residents on the Second floor. Lunch, scheduled for 12:00 p.m., was delayed on two observed occasions. On one day, residents were seated by 11:45 a.m., but lunch trays were not delivered until 1:29 p.m. On another day, residents were seated by 12:07 p.m., with trays delivered at 1:28 p.m. and substitutions by 2:06 p.m. This did not meet the residents' needs and preferences.
The facility failed to inform residents of their rights and responsibilities upon admission, affecting three residents. During a Resident Council meeting, it was noted that some residents had not received or reviewed their rights. Admission packets for two residents were reviewed significantly late, and the admissions staff acknowledged the need for improvement in timely paperwork completion.
A resident with aphasia and muscle weakness did not receive necessary feeding assistance during meals, despite having a puree diet order and a requirement for 1:1 assistance. The facility's Red/Yellow Program failed to include the resident, and staff were unaware of the red napkin's significance, resulting in the resident eating only pudding without help.
A resident with Respiratory Failure and Obstructive Sleep Apnea used a CPAP machine brought from home, which was found with a cloudy and discolored water tank, indicating poor maintenance. The facility lacked appropriate orders, a care plan, and a maintenance log for the CPAP machine. A nurse confirmed these deficiencies and the need for regular water changes and cleaning.
A resident with dementia, diverticulitis, and type 2 diabetes experienced significant unplanned weight loss, dropping from 225 to 199 pounds. Despite a Nutrition Evaluation by a Registered Dietitian, there was no physician assessment documented to address the weight loss. Interviews confirmed the lack of physician evaluation for potential medical causes.
The facility failed to maintain accurate medical records for two residents. One resident's wound care treatment was not properly documented in the physician orders, despite approval from the attending physician. Another resident's records contained multiple inaccuracies, including incorrect racial identification and mislabeled documents. These deficiencies highlight issues in the facility's documentation practices.
A facility failed to provide timely medical records to a resident's next of kin. The NHA received a request for records in an electronic format but did not fulfill it due to losing track of the request and difficulties in transferring the information. The facility lacked a log or tracking system for medical record requests.
The facility did not post required contact information for the Pennsylvania Department of Health and the Office of the State Long-Term Care Ombudsman on the first and second floors. This was confirmed during a tour with the Director of Social Services.
The facility did not ensure that the Department of Health Survey results were easily accessible to residents and visitors, as the binder was located behind the main lobby desk and was outdated, containing only results from March 2022. The Director of Social Services confirmed this was the only location for survey results.
A resident with osteoarthritis and muscle weakness was injured due to a nurse aide's failure to follow the care plan requiring a two-person assist with a Hoyer lift for transfers. The aide attempted the transfer alone, leading to the resident sustaining a head injury, hematoma, and lip laceration. The resident was found with facial injuries after being left in bed, and the aide was later terminated for not adhering to the care plan.
The facility failed to ensure secure storage of drugs and biologicals on two units. On Unit One, an LPN left a medication cart unattended and unlocked while administering medications. On Unit Two, another LPN left a cart unattended with medication bottles and a poured cup of medications exposed. Both nurses acknowledged their mistakes.
The facility failed to maintain the confidentiality of residents' medical information on two nursing units. On both units, licensed nurses left medication carts unattended with computer screens open, displaying identifiable resident information. Both nurses acknowledged their mistakes.
Failure to Notify Ombudsman of Emergency Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for nine consecutive months, from January to September 2024. This deficiency was identified through clinical record reviews and staff interviews. The Nursing Home Administrator, Employee E1, admitted that there was no evidence of such notifications being sent, attributing the oversight to the social worker being new to the facility. Specific instances included the transfer of a resident to the hospital with pneumonia on May 15, 2024, and another resident's hospital transfer on December 18, 2023. In both cases, no ombudsman notification was available for review, as confirmed by Employee E1 during an interview on October 3, 2024.
Failure to Provide Anonymous Grievance Filing
Penalty
Summary
The facility failed to ensure that residents and their representatives could file grievances or concerns anonymously. During a facility tour, it was observed that there were no grievance forms readily accessible on the first and second floors, nor were there any locked grievance boxes available for anonymous submissions. The facility's policy, which allows for grievances to be filed anonymously, was not being implemented as the only location for grievance forms was in the social services office, requiring residents or their representatives to request them directly from the Director of Social Services. Interviews with the Director of Social Services confirmed that residents or their representatives had to approach her to fill out and file a grievance, and there was no current method for anonymous submission. Additionally, during a Resident Council meeting, half of the residents present were unaware of where to access grievance forms within the facility. This lack of accessibility and anonymity in the grievance process is a violation of the residents' rights as outlined in the facility's policy and state regulations.
Failure to Honor Dietary Preferences
Penalty
Summary
The facility failed to honor dietary preferences for three residents, leading to dissatisfaction and inappropriate meal service. Resident R97, who is fully cognitively intact, repeatedly informed staff of his dislike for ravioli and egg salad, yet was served ravioli during a meal observation. Despite requesting a hamburger, he was initially told none were available, and was instead given a ham and cheese sandwich, which was not his preference. Similarly, Resident R72, also fully cognitively intact, was on a no-salt diet but found the food too salty. He requested a turkey and cheese sandwich but was offered alternatives that did not align with his preferences, ultimately accepting a peanut butter and jelly sandwich on a hamburger bun out of necessity. Additionally, Resident R65 did not receive the meal items listed on her meal ticket, such as a dinner roll, margarine, and applesauce, and was instead served a different meal. Interviews with the Food Services Manager and the registered dietitian revealed that the kitchen staff were unable to access residents' documented dislikes while assembling trays, leading to inappropriate meal substitutions. The Food Services Manager acknowledged that sandwiches should have been prepared in advance for residents who requested them, and confirmed that hamburgers were indeed available, contradicting the information given to Resident R97.
Delayed Meal Service on Second Floor
Penalty
Summary
The facility failed to ensure that meals and snacks were provided at appropriate times for residents on both the First and Second floors. Observations on the Second floor dining room revealed that lunch, scheduled to be served at 12:00 p.m., was significantly delayed. On September 30, 2024, residents were seated by 11:45 a.m., but the lunch trays were not delivered until 1:29 p.m., with the final tray served at 1:48 p.m. Similarly, on October 2, 2024, residents were seated by 12:07 p.m., but the lunch trays were delivered at 1:28 p.m., with the final tray served at 1:35 p.m. and substitutions delivered by 2:06 p.m. This delay in meal service did not align with the residents' needs, preferences, and requests, as required by the facility's guidelines.
Failure to Timely Inform Residents of Their Rights
Penalty
Summary
The facility failed to inform residents of their rights, rules, regulations, and responsibilities prior to or upon admission for three out of twenty-three residents reviewed. During a Resident Council meeting, it was revealed that some residents had not received or reviewed a copy of their rights. Specifically, Resident R29 was admitted but did not have their admission packet reviewed until several days later. Admissions staff, Employee E3, could not recall why the paperwork was not signed on the day of admission and admitted to not following up promptly. Similarly, Resident R74's admission packet was not reviewed with the resident's representative until over a year after admission, and Employee E3 was not employed at the facility at that time. For Resident R317, the admission packet was not reviewed until months after admission. Employee E3 acknowledged the need for improvement in ensuring timely completion of admission paperwork. These findings indicate a pattern of delayed communication regarding resident rights and responsibilities.
Failure to Provide Feeding Assistance to Resident
Penalty
Summary
The facility failed to provide necessary feeding assistance to a resident identified as being at nutritional risk. The facility had a Red/Yellow Program in place to identify residents needing supervision or assistance during meals, but Resident R80, who required extensive feeding assistance, was not included in this program. During a lunch meal observation, Resident R80 was seen eating only a Styrofoam cup of chocolate pudding without any staff assistance, despite having a puree diet order and a requirement for 1:1 feeding assistance due to a diagnosis of aphasia following a cerebral infarction and muscle weakness. The resident's clinical records indicated a modified barium swallow study recommended a puree diet with thin liquids and 1:1 feeding assistance. Physician's orders also specified that the resident should be sitting upright during meals and have a red napkin to indicate the need for extensive assistance. However, the facility's documentation did not list Resident R80 as needing such assistance, and staff were unaware of the significance of the red napkin, leading to a lack of proper feeding support during meals.
Deficiency in Respiratory Care for Resident Using CPAP
Penalty
Summary
The facility failed to ensure appropriate orders, care plan, and maintenance related to respiratory care for a resident using a CPAP machine. The resident, who was admitted with diagnoses of Respiratory Failure and Obstructive Sleep Apnea, had brought a non-invasive CPAP machine from home. Observations revealed that the water tank of the CPAP machine was very cloudy and the water was light brown in color, indicating a lack of maintenance. The resident confirmed that the tank needed cleaning and the water needed changing. Further review of the resident's clinical record showed no existing order, care plan, or maintenance log for the CPAP machine. An interview with a licensed nurse confirmed the absence of these essential documents and acknowledged the poor condition of the CPAP machine's water tank. The nurse stated that the water should be changed daily and that a cleaning schedule or a new tank should be implemented for the resident's CPAP machine.
Failure to Conduct Physician Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to ensure a physician assessment was completed for a resident experiencing significant unplanned weight loss. Resident R21, who was admitted with diagnoses of dementia, diverticulitis, and type 2 diabetes, experienced an 11.56% weight loss over a period of less than three months, dropping from 225 pounds to 199 pounds. Despite a Nutrition Evaluation being conducted by a Registered Dietitian, there was no documentation in the physician's progress notes addressing the weight loss. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the absence of a physician's assessment regarding the potential medical causes of the resident's weight loss.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents. For Resident R6, the clinical records showed a discrepancy in the documentation of wound care treatment. Although a wound care consultation note recommended a change in treatment to include silver alginate for the left heel, the corresponding physician orders did not include this recommendation. The wound care RN confirmed that the attending physician had approved the use of silver alginate, but the order was not placed in the resident's medical records. For Resident R58, there were multiple inaccuracies in the clinical records. The resident's Minimum Data Set inaccurately identified the resident's race, and a 'Notice of Medicare Non-Coverage' was mislabeled under another resident's name. Additionally, a 'change in condition assessment' contained a future date for the onset of altered mental status. These errors indicate a lack of attention to detail in maintaining accurate and complete medical records for the residents.
Failure to Provide Timely Medical Records
Penalty
Summary
The facility failed to provide copies of medical records as requested in a timely manner for a resident, identified as Resident R317. The next of kin of the resident requested medical records from January 1, 2021, to October 31, 2022, in an electronic format. The Nursing Home Administrator (NHA), identified as Employee E1, received the request on May 29, 2024, but the request was never fulfilled. The NHA admitted to losing track of the request due to the need to coordinate with the facility's corporate quality assurance team to send the documents. Additionally, the NHA faced difficulties transferring the information onto an external disk. It was revealed that the facility did not maintain a log or tracking system for medical record requests, and no such records were kept by the medical records personnel.
Failure to Post Required Contact Information
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting the contact information for the Pennsylvania Department of Health and the Office of the State Long-Term Care Ombudsman program on two of its four nursing units, specifically the first and second floors. This deficiency was identified during a facility tour conducted on October 1, 2024, at 11:00 a.m. with the Director of Social Services, Employee E7. During the tour, it was observed that the first-floor unit lacked the required posting for the Office of the State Long-Term Care Ombudsman, and the second-floor unit had no postings for either the Pennsylvania Department of Health or the Ombudsman program. These findings were confirmed by Employee E7.
Inaccessible and Outdated Survey Results
Penalty
Summary
The facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in two nursing units, specifically the first and second floors. During a facility tour conducted with the Director of Social Services, it was observed that the survey results binder was located behind the desk in the main lobby, making it inaccessible without asking for assistance. Additionally, the binder was not up to date, containing only the results from the annual survey dated March 11, 2022. The Director of Social Services confirmed that this was the only location where the survey results were available, indicating a lack of compliance with accessibility requirements.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse and neglect, resulting in actual harm. The resident, who had a history of osteoarthritis, muscle weakness, and was dependent on staff for transfers, sustained a head injury, hematoma, and lip laceration. The resident's care plan required a two-person assist with a Hoyer lift for transfers, but this protocol was not followed. On the day of the incident, a nurse aide attempted to transfer the resident to bed alone, without using the required Hoyer lift or assistance from another staff member. During the transfer, the resident became combative, and the aide left the resident in bed and closed the door. Shortly after, another staff member heard the resident screaming for help and found the resident with facial injuries. The charge nurse and supervisor were notified, and the resident was sent to the hospital for evaluation. The facility's investigation revealed that the nurse aide admitted to not following the care plan and performing an inappropriate transfer. There was no evidence that the resident had self-harming behaviors or that the injuries were self-inflicted. The nurse aide was suspended and later terminated for failing to adhere to the resident's care plan, which contributed to the resident's injuries.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards on two observed units. On Unit One, a medication cart used by a licensed nurse was left unattended and unlocked outside a resident's room. The nurse admitted to being nervous and acknowledged the mistake when it was pointed out. This incident occurred while the nurse was preparing and administering medications to a resident. On Unit Two, another medication cart was found unattended with five medication bottles and a cup of poured medications left out. The licensed nurse responsible for the cart was not in sight and later explained that she had gone into a resident's room to talk with them. The nurse confirmed that she should not have left the cart unattended with medications exposed. These observations indicate a failure to adhere to the facility's policy on the secure storage of drugs and biologicals.
Confidentiality Breach of Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on two nursing units. On Unit One, a medication cart used by a licensed nurse was left unattended with the computer screen open, displaying identifiable resident information. The nurse left the cart unlocked and the screen visible while administering medications in a resident's room. Upon returning, the nurse acknowledged the mistake, attributing it to nervousness. On Unit Two, a similar incident occurred where another licensed nurse left a medication cart unattended with the computer screen open, showing identifiable resident information. The nurse was not in sight and later explained that she had entered a resident's room to speak with them after hearing their voice. She confirmed that she should not have left the cart unattended with the information visible. These actions were in violation of the facility's policy on resident rights and confidentiality.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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