Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Rittenhouse Post Acute during CMS and state inspections, most recent first.
A resident with diagnoses including convulsions and a prescription for seizure medication did not have a care plan addressing seizure management. Review of clinical records and staff interview confirmed that the care plan lacked goals and interventions for seizures, despite the resident's documented need.
A resident with a seizure disorder did not receive prescribed doses of Lamotrigine and Lacosamide because the facility's pharmacy failed to deliver the medications as ordered. The MAR and nursing documentation confirmed the missed doses, and the DON verified that the medications were unavailable due to pharmacy delivery issues, despite facility policy requiring 24/7 pharmacy services.
A resident with documented muscle weakness, abnormal gait, and a need for standby assist during ambulation was sent to an outside medical appointment without an escort, despite facility policy and care plan requirements. The resident, using a rolling walker, was left unsupervised after ambulance drop-off, tripped over a mat in the building lobby, and sustained a nasal fracture.
A resident who requested and was approved for an earlier discharge from Medicare Part A services was not provided with the required Notification of Medicare Non-Coverage. The staff member responsible confirmed that the notice was not given, despite being aware of the resident's change in discharge plans.
A resident with multiple chronic conditions and moderate cognitive impairment experienced significant weight loss, but the facility did not develop or implement a comprehensive care plan with measurable goals or interventions to address the weight loss or the resident's pescatarian dietary preferences. The care plan lacked individualized strategies and did not reflect the resident's nutritional needs, as confirmed by staff and policy review.
Two residents experienced significant unaddressed weight loss due to the facility's failure to monitor, reweigh, and update care plans or implement timely dietary interventions, despite clear indications of nutritional risk and documented weight changes.
Two residents with PTSD did not receive trauma-informed or culturally competent care as required. There was no documented assessment or care planning related to their PTSD, and no evidence that services were provided to address their diagnoses. A psychiatric evaluation for one resident also failed to mention or address PTSD.
A resident was found to be self-administering a magnesium supplement without a physician's order or assessment for self-administration. An LPN was unaware of the supplement use, and facility policy requiring prescriber orders for all medications was not followed, resulting in a significant medication error.
A resident's inhaler was found unsecured on an overbed table instead of in a locked compartment, and an open vial of tuberculin purified protein derivative in the medication room refrigerator was not dated. The DON confirmed both deficiencies, which were not in accordance with facility policy for medication storage and labeling.
The facility did not employ a qualified registered dietitian, as the individual in the role had not completed the required licensure exam and was working under supervision without proper credentials. This unlicensed dietitian was solely responsible for assessing and documenting a resident's significant weight loss, with no evidence of review or consultation by a licensed dietitian.
The facility's activities program was directed by a social worker who lacked the necessary qualifications. The social worker, responsible for overseeing the program, did not possess a license or registration as a qualified therapeutic recreation specialist or activity professional. Additionally, she lacked the required experience and training, and was unaware of the qualification requirements.
The facility failed to adhere to professional standards for food service safety. Observations revealed that the high temperature dishwasher had incorrect wash and rinse cycle temperatures, and expired food products were found in the dry storage area. The Dietary Director confirmed these issues and stated that the facility was addressing the inaccurate dishwasher readings.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for several residents with conditions requiring such measures, including open wounds and urinary catheters. Observations showed a lack of PPE use by staff during care, despite signs indicating EBPs were needed. Delays in ordering EBPs and interviews with staff confirmed the deficiency in infection control practices.
The facility did not notify the Office of the State LTC Ombudsman of emergency transfers as required. A resident was transferred to a hospital due to medical conditions, but the facility failed to provide evidence of notification. An employee confirmed that no notifications were made for any hospital transfers.
A facility failed to conduct a comprehensive pain assessment with direct observation and communication for a resident who had knee surgery. The MDS coordinator completed the assessment remotely, relying on documentation from other staff, leading to inaccuracies in the recorded pain levels and the resident's reported experience. This resulted in a failure to accurately reflect the resident's condition in the care plan.
A resident's pain assessment was inaccurately documented in the MDS, showing discrepancies between reported pain levels and actual documented pain. The assessment was completed remotely by an employee who did not directly interview the resident, leading to inaccurate documentation of the resident's pain experience.
The facility failed to provide a written summary of the baseline care plan to three residents, as required by policy. Interviews and record reviews confirmed that the residents did not receive documentation outlining their initial care goals, medications, dietary instructions, and services. The DON acknowledged this oversight, indicating a lapse in compliance with resident care policies.
A resident admitted after back surgery did not receive the ordered wound care, leading to an infection. The facility failed to clean and monitor the surgical incision as instructed by the hospital, resulting in the resident requiring antibiotics. The DON confirmed the lapse in care.
A resident did not receive prescribed medications due to unavailability from the pharmacy, as confirmed by the Director of Nursing. This failure to provide necessary pharmaceutical services was identified through a review of records and interviews.
The facility did not ensure the attendance of an Infection Preventionist at the quarterly QAPI meetings for four consecutive quarters. A review of meeting attendees lists for October 2023, January 2024, and April 2024 showed the absence of an Infection Preventionist, and no documentation was available for July 2024. This was confirmed by an interview with a clinical administrative staff member.
Failure to Develop Seizure Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the diagnosis of seizures for one resident. Clinical record review showed that the resident had multiple diagnoses, including depression, back pain, convulsions, and cerebral infarction, and was prescribed medication for seizure management. Despite these documented conditions and treatments, the resident's person-centered care plan did not include any goals or interventions related to seizure care. This omission was confirmed by the Director of Nursing during an interview, who acknowledged that no care plan for seizures was in place for the resident.
Failure to Provide Timely Pharmacy Services for Seizure Medications
Penalty
Summary
The facility failed to ensure timely delivery and administration of prescribed seizure medications for a resident, as required by physician orders and facility policy. The resident had documented orders for Lamotrigine and Lacosamide to be administered at specific times for seizure management. On the evening of August 9, 2025, the resident did not receive the 9:00 p.m. doses of both Lamotrigine and Lacosamide because the medications were not delivered by the facility's pharmacy. This omission was confirmed by review of the Medication Administration Record (MAR) and a nursing note, which documented that the resident did not receive the prescribed seizure medications during the overnight shift. Facility policy, revised in April 2019, requires that pharmacy services be available 24/7 to ensure residents have a sufficient supply of prescribed medications and receive them in a timely manner. Despite this policy, the resident's seizure medications were not available for administration as ordered, and the DON confirmed the failure was due to the pharmacy not delivering the medications. The physician was notified of the missed doses, as documented in the nursing note.
Failure to Provide Required Supervision During Resident Transport Results in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who required supervision and assistance with ambulation was sent to an outside medical appointment without an escort, contrary to facility policy. The resident had a history of muscle weakness, abnormal gait, and impaired balance, as documented in clinical records and therapy assessments. The care plan and therapy evaluations consistently indicated the need for standby assistance during ambulation, especially on uneven surfaces and in community settings. On the day of the incident, the resident was transported by ambulance to a medical appointment. Upon arrival, the resident was dropped off in front of the building and proceeded to walk into the building unassisted, using a rolling walker. There was no staff member or family escort present to provide the required supervision. The resident subsequently tripped over a thick mat in the lobby, resulting in a fall and a fractured nasal bone. Facility policies reviewed in the report specified that residents requiring supervision should be accompanied by staff if family is unavailable, and that individualized safety interventions must be communicated and implemented. Despite these policies and the resident's documented need for supervision, the facility failed to provide an escort, leading to actual harm. Staff interviews confirmed the resident's ongoing need for standby assistance and the lack of supervision at the time of the fall.
Failure to Provide Notification of Medicare Non-Coverage Upon Early Discharge
Penalty
Summary
The facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) to a resident who was being discharged from Medicare Part A services. Documentation review showed no evidence that the NOMNC was given to the resident. The Director of Social Services, who was responsible for sending the NOMNC, confirmed during an interview that the resident was originally scheduled to leave on a later date but requested to leave earlier. The resident communicated this request a few days prior to the new discharge date, and after being cleared by the rehab department, was discharged. The Director of Social Services acknowledged that the NOMNC should have been provided but was not.
Failure to Develop and Implement Comprehensive Care Plan for Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's nutritional needs and significant weight loss. Despite the resident being admitted with multiple diagnoses including coronary artery disease, hypertension, diabetes, aphasia, malnutrition, and depression, and having a moderate cognitive impairment, the care plan did not include measurable objectives, timetables, or specific interventions related to the resident's documented weight loss. The resident experienced a notable weight loss from 118.0 pounds at admission to 102.8 pounds within a short period, yet the care plan lacked focus areas, goals, or interventions to address this decline. Additionally, the care plan did not reflect the resident's dietary preferences or supplemental needs associated with a pescatarian diet, even though the dietitian and kitchen staff had worked to accommodate these preferences. There was no documentation of menu choices for pescatarian diets, and the care plan did not address the resident's need for oral nutrition supplements or other individualized interventions. These omissions were confirmed by staff interviews and review of facility policies, which require ongoing assessment and multidisciplinary care planning for weight loss and nutritional risk.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor, implement, and modify nutritional interventions for two residents, resulting in unaddressed significant weight loss. For one resident with a history of lumbosacral and pelvic fractures, weight records showed a loss of 9.2 lbs (5.14%) over ten days, but there was no evidence of a required reweigh or timely dietary intervention. The resident's care plan, which already identified risk for malnutrition, was not updated to reflect the significant weight loss, and the dietitian did not assess the resident until after the weight loss had occurred. Another resident, admitted with multiple diagnoses including coronary artery disease, diabetes, malnutrition, and moderate cognitive impairment, experienced a weight loss of 15.2 lbs (12.7%) within one month. Despite repeated weight warnings and documentation indicating the need for a reweigh, there was no evidence that a reweigh was performed. The resident's dietary preferences were not met, and the care plan to provide oral nutritional supplements was not fully implemented. The dietitian was aware of the weight loss but had not completed a comprehensive assessment or documented interdisciplinary team notification. Both cases demonstrated a lack of adherence to the facility's own policies regarding weight monitoring, timely reweighs, and prompt dietary interventions. Documentation and staff interviews confirmed that significant weight changes were not properly addressed, and care plans were not updated to reflect the residents' changing nutritional needs.
Failure to Provide Trauma-Informed, Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice for two residents diagnosed with PTSD. Review of the clinical records for both residents revealed that there was no documented evidence of an assessment related to PTSD being conducted. Additionally, there was no documentation indicating that either resident received services to address their PTSD diagnoses. The facility's policy requires universal screening and assessment for trauma, as well as individualized care planning to address trauma-related needs, but these steps were not followed for the residents in question. Further review showed that for one resident, a psychiatric evaluation was performed, but the PTSD diagnosis was not mentioned or addressed in the evaluation. Neither resident had a care plan that addressed their PTSD diagnosis, despite this being a requirement under the facility's trauma-informed care policy. These omissions indicate that the facility did not account for the residents' past experiences and preferences, nor did it take steps to eliminate or mitigate potential triggers that could cause re-traumatization.
Resident Self-Administers Magnesium Supplement Without Physician Order
Penalty
Summary
A deficiency was identified when a resident was found to be self-administering a magnesium supplement without a physician's order. Facility policy requires that all medications, including supplements, be administered according to prescriber orders, and that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team have determined the resident has the capacity to do so safely. Review of the resident's clinical record showed no order for magnesium, and there was no documentation that the resident had been assessed or approved to self-administer this supplement. During a medication pass observation, a licensed nurse was seen administering morning medications to the resident, and a bottle of magnesium gummies was observed on the resident's table. The resident stated she takes the gummies twice daily, and the nurse confirmed there was no order for this supplement and was unaware the resident was consuming it. This failure to ensure medications and supplements were administered according to policy and prescriber orders resulted in a significant medication error for the resident.
Failure to Securely Store and Properly Label Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely and in accordance with professional standards. During an observation, a Fluticasone inhaler labeled with a resident's name was found on top of the resident's overbed table, rather than being stored in a locked compartment as required by facility policy. The resident, who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a physician's order for the inhaler, confirmed that nurses had given her the medication but could not recall which nurse provided it. The inhaler remained unsecured during a follow-up observation with the Director of Nursing. Additionally, an inspection of the medication refrigerator in the medication room revealed an open vial of tuberculin purified protein derivative that was not dated. The Director of Nursing confirmed that the vial was not labeled with the date it was opened, which is contrary to facility policy requiring multi-dose vials to be dated upon opening. These findings demonstrate lapses in the secure storage and proper labeling of medications and biologicals within the facility.
Failure to Employ Qualified Registered Dietitian
Penalty
Summary
The facility failed to employ a qualified registered dietitian as required by regulations. Review of the dietitian's job description outlined responsibilities such as assessing nutritional needs, developing individualized nutrition care plans, conducting nutrition-focused physical exams, and collaborating with the interdisciplinary team. However, the individual serving as the registered dietitian had not completed the mandatory LDN licensure exam and was working under the direct supervision of a regional dietitian. Interviews with facility staff confirmed that the dietitian had not obtained the required licensure. Further review of resident records showed that the unlicensed dietitian was the only staff member documenting and reviewing clinical notes related to significant weight loss for a resident. There was no evidence that a licensed dietitian reviewed or consulted on any clinical documents, nor was there a cosignature or indication of oversight by the regional dietitian. This lack of qualified oversight and documentation directly contributed to the deficiency cited.
Unqualified Staff Directing Activities Program
Penalty
Summary
The facility's activities program was not directed by a qualified professional as required by regulations. During an interview, the nursing home administrator and regional staff member confirmed that the social worker, Employee E8, was overseeing the facility's activity program, including programs and assessments, despite not having the necessary qualifications. Employee E8 admitted to lacking a license or registration as a qualified therapeutic recreation specialist or activity professional. She also did not have two years of experience in a social or recreational program within the last five years, with at least one year in a therapeutic activities program. Furthermore, she was not a qualified occupational therapist or occupational therapy assistant and had not completed a state-approved training course. Employee E8 acknowledged her lack of qualifications and was unaware of the requirement to be a qualified activity professional or director.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations in the main kitchen dish room area revealed that the high temperature dishwasher machine had a wash cycle temperature of 172°F and a final rinse cycle temperature of 515°F, which were not in accordance with the manufacturer's instructions. A follow-up observation showed a wash cycle temperature of 170°F and a final rinse cycle temperature of 210°F. The Dietary Director confirmed these temperatures and stated that the facility was in contact with the manufacturer to address the inaccurate readings on the digital thermostat. Additionally, during an observation in the main kitchen dry storage area, it was found that there were four boxes of cornbread mix dated June 2024, one container of molasses with an expired date, one container of cooking wine dated February 1, 2024, and loaves of bread that were not dated. The Dietary Director confirmed that the facility failed to dispose of expired food products.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish Enhanced Barrier Precautions (EBPs) for five out of six residents reviewed, which is necessary to prevent the spread of multi-drug resistant organisms (MDROs). Observations revealed that signs for EBPs were posted at the doors of certain resident rooms, but there were no isolation carts or supplies available nearby. Interviews with residents indicated that staff were not wearing gowns during care activities that required EBPs, such as incontinence care. Clinical records showed that residents with conditions like open wounds, urinary catheters, and recent surgeries were not placed on EBPs in a timely manner, with orders for EBPs being delayed until after the residents were admitted. Specific cases included residents admitted with spinal surgery, open wounds, urinary catheters, and positive cultures for Group A hemolytic strep, all of whom required EBPs. However, the necessary precautions were not implemented promptly, as evidenced by the lack of PPE use by staff during direct care. Interviews with staff confirmed that EBPs should have been in place for these residents due to their medical conditions, but the facility did not ensure that the appropriate measures were taken to protect both residents and staff from potential infection risks.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required. This deficiency was identified through a review of facility documentation, clinical records, and staff interviews. Specifically, the progress notes for a resident indicated that the resident was transferred to a local hospital emergency department due to medical conditions. However, the facility did not provide evidence of notification to the Ombudsman regarding this transfer. An interview with an employee confirmed that the required notification was not made for this resident or any other hospital transfers.
Failure to Conduct Direct Pain Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment with direct observation and communication for a resident, as required by regulations. The deficiency was identified during a review of facility documentation, clinical records, and staff interviews. Specifically, the Resident Assessment Instrument (RAI) manual guidelines for pain assessment were not followed. The guidelines emphasize the importance of obtaining pain information directly from the resident to ensure accurate and individualized care planning. However, the assessment for the resident in question was completed remotely by an MDS coordinator without direct interaction with the resident. The resident, who had undergone knee surgery, reported experiencing severe pain that affected her sleep, therapy, and daily activities. Despite this, the Minimum Data Set (MDS) assessment documented inaccurate responses regarding the resident's pain levels and its impact on her activities. The MDS coordinator relied on documentation from other staff rather than conducting a direct interview with the resident. This lack of direct assessment led to discrepancies in the recorded pain levels and the resident's reported experience, resulting in a failure to accurately reflect the resident's condition in the care plan.
Inaccurate Pain Assessment for Resident
Penalty
Summary
The facility failed to complete comprehensive assessments that accurately reflected the resident's status for one of the eight residents reviewed. Specifically, for Resident R62, the Minimum Data Set (MDS) assessment conducted on August 13, 2024, included a pain assessment that was found to be inaccurate. The MDS documented that the resident experienced pain frequently, with a worst pain rating of 7 on a scale of zero to ten. However, a review of the pain assessment for the same period revealed that the resident had a highest documented pain level of 10 from August 9 to August 13, 2024. An interview with the Regional MDS coordinator, Employee E6, revealed that the assessment was completed by Employee E7, who worked remotely and did not conduct a direct interview with the resident. Instead, the information was obtained from documentation completed by other staff. Employee E6 confirmed that there was no source documented in the clinical record for responses related to the effect of pain on sleep, therapy, and day-to-day activities, as documented in the MDS. This discrepancy led to the conclusion that the responses and pain scale documented in the record were inaccurate.
Failure to Provide Baseline Care Plan to Residents
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to three residents, which is a requirement under the facility's policies and regulations. Interviews with the residents revealed that they did not receive a copy of the baseline care plan, which should have included the initial goals for the resident, a summary of medications, dietary instructions, and the services and treatments to be administered by the facility. This deficiency was confirmed through interviews with the residents and a review of their clinical records, which showed no evidence of the baseline care plan being provided. The Director of Nursing confirmed that the facility did not provide the required written summary of the baseline care plan to the residents or their representatives. This oversight affected the residents' understanding of their care plan and the services they were to receive upon admission. The deficiency was identified during a review of facility policies, clinical records, and staff interviews, highlighting a lapse in the facility's adherence to its resident care policies as outlined in 28 Pa Code 211.10(d).
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide care and services to a surgical wound according to professional standards of practice and as ordered by the physician for a resident who had undergone back surgery. The resident, identified as R65, was admitted to the facility from the hospital with a surgical incision on her back. The hospital records indicated an order to clean the incision with soap and water daily and to monitor for changes or signs of infection. However, the facility did not adhere to these instructions, as there was no evidence of the wound being cleaned or monitored from August 14 to August 20, 2024. The resident reported that the facility staff did not monitor or clean the incision for several days after her admission, leading her to contact her physician and complain to the staff. As a result of this neglect, the incision became infected, and the resident required antibiotics. The Director of Nursing confirmed that the facility did not provide the appropriate treatment as ordered by the hospital and failed to monitor the incision as recommended.
Failure to Provide Necessary Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for a resident, identified as R64, as determined through a review of facility documentation, clinical records, and interviews. The physician had ordered several medications for the resident, including Amlodipine, Atorvastatin, Ezetimibe, Repatha, Venlafaxine, Metoprolol, and Ramipril, all of which were to be administered on August 18, 2024. However, the Medication Administration Record indicated that these medications were not administered at the scheduled times. An interview with the Director of Nursing confirmed that the medications were not available from the pharmacy to be administered as ordered. This lack of availability led to the resident not receiving their prescribed medications, which constitutes a failure in providing necessary pharmaceutical services. The deficiency was noted under the Pennsylvania Code sections related to the responsibility of the licensee and pharmacy services.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist or their designee attended the quarterly Quality Assurance Process Improvement (QAPI) committee meetings for all four quarters reviewed, from October 2023 through July 2024. A review of the QAPI committee meeting attendees list for October 2023, January 2024, and April 2024 revealed the absence of an Infection Preventionist. Additionally, there was no sign-in sheet or QAPI information available for July 2024. An interview with Clinical Administrative staff, Employee E5, confirmed that no Infection Preventionist attended the QAPI meetings during the specified period.
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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) |
|---|---|---|---|---|
| University City Rehabilitation And Healthcare Ctr | 0.6 mi | ★★★★★ | 11 | 0 |
| West Park Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 17 | 0 |
| Centennial Healthcare And Rehabilitation Center | 1 mi | ★★★★★ | 25 | 0 |
| Renaissance Healthcare & Rehabilitation Center | 1.5 mi | ★★★★★ | 15 | 0 |
| Logan Square Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 26 | 0 |
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