Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Renaissance Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Meals and beverages were not served according to the posted schedule, and residents reported repeated delays in receiving food. Observations showed residents waiting for the noon meal while dietary delivery was not completed until much later, and an LPN confirmed the second-floor unit had been waiting beyond the mealtime schedule on a daily basis for months. Resident council minutes and resident interviews documented ongoing complaints that meal trays and food trucks were arriving late, and some residents said the food was often cold when served.
A resident with osteoarthritis, osteoporosis, and osteopenia was not care planned for her osteoporosis or high fracture risk. After the resident reported right-sided pain and an x-ray showed a 9th rib fracture, records noted severe osteoporosis and very high fracture risk, but the care plan had no goals or interventions for these conditions, and the DON confirmed no care plan had been developed.
A resident with dementia and high fall risk was lowered to the floor during toileting and later found bleeding under the right axilla after a shower. The record showed no nursing assessment or monitoring when the wound was first discovered, and a late entry noted the skin issue had not been evaluated. The next day, the wound specialist found a large open area with muscle exposure and sanguineous drainage, and the resident was sent to the hospital where the laceration required sutures.
A resident with diabetes did not receive a follow-up ophthalmology appointment after an eye exam for suspected glaucoma and cataracts instructed annual monitoring. The resident stated it had been a while since the last eye doctor visit and believed they were due, and the DON confirmed the facility could not locate a yearly ophthalmology follow-up.
Incomplete dialysis communication and documentation. The facility failed to maintain ongoing communication with the dialysis provider for two residents receiving dialysis. One resident’s dialysis communication forms were missing key clinical details such as vital signs, code status, changes in condition, and weight/fluid information, while another resident’s dialysis log pages were not completed or signed by the dialysis center. Staff confirmed the missing documentation and stated the facility often had to call the dialysis center for pre- and post-weights.
A resident with A-FIB, HTN, and hemiplegia/hemiparesis after cerebral infarction did not receive ordered apixaban and calcium plus vitamin D3 because the meds were unavailable at the time of administration. The LPN observed the meds were not on hand, the apixaban refill had been untimely reordered, and the e-MAR was later documented inaccurately as given; the DON confirmed the missed apixaban dose.
Medication error rate exceeded 5 percent. Surveyors observed 2 errors during 25 medication opportunities, resulting in an 8 percent error rate. For one resident with A-FIB, HTN, and hemiplegia/hemiparesis after cerebral infarction, an LPN did not administer ordered Apixaban 5 mg and calcium plus vitamin D3 because the medications were unavailable, and the DON confirmed the resident did not receive them as prescribed.
Failure to provide routine dental care for a resident with oral health needs. The resident had visible food debris, plaque, calculus, and gum bleeding, and the dental hygienist noted the resident was not tolerating cleaning and needed a dentist exam. The resident also complained of tooth pain, and an LPN confirmed no routine dental services were scheduled to address the oral issues.
A resident with A-FIB, HTN, and hemiplegia/hemiparesis had orders for calcium plus vitamin D3 and apixaban 5 mg q12h. During observation, an LPN did not administer the medications because they were unavailable, and the apixaban was untimely re-ordered. The e-MAR later showed apixaban as given, and the DON confirmed the missed dose and inaccurate documentation.
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.
Late Meal Delivery and Inconsistent Meal Service
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests. The facility’s policy stated that meals were to be provided within the scheduled mealtime frame and at regular times to ensure each resident received at least three meals a day, but observations showed the posted meal delivery schedule was not being followed. On the second-floor nursing unit, residents were sitting in the dining room or in their rooms at 11:30 a.m. waiting for the noon meal, and the food and beverage delivery from dietary was not completed until 1:30 p.m., which was 1.5 hours beyond the established schedule. Residents were heard asking staff where the food and fluids were because they were hungry after waiting for two hours for the final meal truck to arrive. Interviews and meeting minutes showed the late meal delivery had been an ongoing concern. The dietary services director stated that new kitchen staff were not familiar with their job responsibilities and confirmed meals were not being delivered promptly in accordance with the posted schedule. An LPN reported that second-floor nursing staff had been waiting at least an hour beyond the established mealtime schedule on a daily basis for several months. Resident council and food committee minutes from June, July, and August documented repeated resident concerns that meal trays and food trucks were arriving late to the nursing units and that dietary services were not operating in a timely manner. During a group meeting, alert and oriented residents stated meals had been late recently, and some reported that food was often cold when received. On the first-floor dining room, residents received beverages at 12:33 p.m. and were not served meals until 1:00 p.m.
Failure to Care Plan for Osteoporosis and Fracture Risk
Penalty
Summary
Facility failed to develop a care plan related to Resident R133’s diagnosis of osteoporosis. Review of the resident’s clinical record showed diagnoses of osteoarthritis, osteoporosis, and osteopenia. Facility documentation showed that on May 6, 2025, the resident complained of pain on the right side and stated it may have occurred when a nurse aide was repositioning her in bed; an x-ray later revealed a fracture of the 9th rib. Hospital records indicated the resident was at high risk for fractures due to severe osteoporosis. A facility investigation completed by the DON on June 5, 2025, documented that the medical director reviewed the resident’s condition and noted severe osteoporosis since 2016 with very high risk for fractures. Review of the resident’s care plan found no goals or interventions related to the resident’s high fracture risk or osteoporosis, and the DON confirmed there was no care plan developed for the diagnosis.
Failure to Assess and Monitor a Post-Fall Laceration
Penalty
Summary
The facility did not ensure that Resident R17 received treatment and care in accordance with professional standards of practice after a fall-related incident that resulted in a laceration. Resident R17 was admitted in March 2022 with a diagnosis of dementia and was assessed as high risk for falls. On July 7, 2025, the resident was lowered to the floor by a nurse aide while being toileted, was soiled, and received a shower after the incident. Staff then noted that the resident was bleeding under the right axillary area. The clinical record contained no evidence of a nursing assessment at the time the wound was first discovered and no evidence of monitoring by nursing when the wound was identified. A late entry note created on July 13, 2025, stated that the resident had a fall on July 7, 2025, at 10:39 a.m. and that skin issues had not been evaluated. The following morning, the wound was assessed by the wound specialist as a large open area with muscle exposure and moderate sanguineous drainage from the right arm. The resident was then sent by 911 to the hospital, where the wound was described as a 7 x 5 cm laceration deep to muscle that required sutures. The DON was unable to show evidence of the initial wound assessment, treatments, physician orders, or ongoing monitoring before the transfer to the hospital.
Failure to Arrange Annual Ophthalmology Follow-Up
Penalty
Summary
The facility failed to ensure that Resident R83 received services to maintain vision. Resident R83 was admitted in November 2021 and had a diagnosis of diabetes. During an interview on September 8, 2025, the resident stated it had been a while since the last eye doctor appointment and said, "I think I'm due." Review of the clinical record showed an ophthalmology appointment on March 6, 2024, for suspected glaucoma and cataracts, with instructions to monitor annually. Further review found no additional ophthalmology appointments had been made, and the Director of Nursing confirmed on September 10, 2025, that the facility could not locate a follow-up appointment for the resident's yearly ophthalmology evaluation.
Incomplete Dialysis Communication and Documentation
Penalty
Summary
The facility failed to maintain ongoing communication between the facility and the dialysis provider for two residents receiving dialysis. One resident had diagnoses of end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus, with a physician order for dialysis on Mondays, Wednesdays, and Fridays. Review of the resident’s dialysis communication reports showed missing information on multiple occasions, including missing vital signs, code status, changes in condition, facility nurse name/date, pre-weight information, and post-weight/total fluid removed information. Another resident had a physician order for hemodialysis every Tuesday, Thursday, and Saturday with a 10:45 a.m. chair time at a local dialysis center. Review of that resident’s dialysis log record showed that none of the four pages available from September were completed by the dialysis center or signed by the dialysis center nurse. Staff interviews confirmed that the dialysis center had not completed the documentation for those pages and that the facility often had to call the dialysis center for pre- and post-weights. The Unit Clerk stated the dialysis center had not completed the log pages and that she would have to call them, and the DON acknowledged that the log sheets should be completed each time the resident goes to dialysis by both the facility nurse and dialysis center staff.
Medication Not Available for Ordered Dose
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident R24 when ordered medications were not available at the time of administration. Resident R24 had diagnoses of paroxysmal atrial fibrillation, high blood pressure, and hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side. The resident had physician orders for calcium plus vitamin D3 twice daily and apixaban 5 mg every 12 hours for A-FIB. During medication administration observation, the LPN did not administer the calcium plus vitamin D3 supplement or apixaban because the medications were unavailable, and the apixaban had been untimely reordered. A nurse note documented that the CRNP/MD was aware of the missed apixaban dose and that the medication would be delivered from the pharmacy. The e-MAR later showed apixaban as given, but the DON confirmed that the resident missed the apixaban dose and that the e-MAR documentation was inaccurate.
Medication error rate exceeded 5 percent
Penalty
Summary
The facility did not ensure that the medication error rate remained below 5 percent. Based on observation of 25 medication opportunities, surveyors identified 2 medication errors, resulting in an 8 percent medication error rate. Facility policy stated that medications are to be administered within one hour of the prescribed time unless otherwise specified, and refills are preferably requested through the EMAR system or by faxing the refill order form to the pharmacy. For Resident R24, the clinical record showed diagnoses of paroxysmal atrial fibrillation, high blood pressure, and hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side. The resident had physician orders for Apixaban 5 mg every 12 hours at 9 a.m. and 9 p.m. for A-FIB and calcium plus vitamin D3 twice daily. During medication administration observation, the LPN did not administer the supplement or Apixaban because the medications were unavailable, and the Apixaban had been untimely re-ordered from the pharmacy. The DON later confirmed that the resident did not receive the Apixaban 5 mg or the calcium plus vitamin D3 supplement as prescribed.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide prompt and routine dental care for one resident reviewed for oral health services. The facility policy stated that it was responsible for ensuring each resident received oral health examinations and assessments, and that routine and emergency dental care would be provided by a contracted dental group. Resident R9 was observed on September 8, 2025, and was noted to need oral care, with visible food debris between the teeth when the resident smiled. The clinical record showed that the resident had been evaluated by the dental hygienist on July 18, 2025, and the assessment documented moderate to severe calculus, moderate to severe plaque, and moderate to severe gum bleeding. The hygienist noted that the resident was not tolerating the cleaning and needed to be examined by a dentist. A dental assessment dated [DATE] documented that the resident complained of tooth pain and requested to be examined by a dentist. During interview, the LPN confirmed that there were no routine dental services scheduled to address the resident’s oral needs, including tooth pain, plaque, calculus, and bleeding gums.
Inaccurate e-MAR Documentation and Missed Apixaban Dose
Penalty
Summary
The facility failed to maintain accurate medication administration records for Resident R24. R24 had diagnoses of paroxysmal atrial fibrillation, high blood pressure, and hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side. The resident had physician orders for calcium plus vitamin D3 twice daily and apixaban 5 mg every 12 hours for A-FIB. During medication administration observation, the licensed nurse did not administer the calcium plus vitamin D3 supplement or apixaban because the medications were unavailable, and the apixaban was untimely re-ordered. The resident’s e-MAR later showed apixaban 5 mg documented as given at 10:56 a.m., and the DON confirmed that the resident missed the apixaban dose and that the e-MAR documentation was inaccurate.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holy Family Home | 0.6 mi | ★★★★★ | 8 | 0 |
| University City Rehabilitation And Healthcare Ctr | 1.1 mi | ★★★★★ | 11 | 0 |
| West Park Rehabilitation And Nursing Center | 1.2 mi | ★★★★★ | 17 | 0 |
| Rittenhouse Post Acute | 1.5 mi | ★★★★★ | 2 | 0 |
| Care Pavilion Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 51 | 0 |
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