Renaissance Healthcare & Rehabilitation Center

Based on review of facility policy, observation, and interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that grievance or complaint forms were available to residents or their representatives without asking for two of two units reviewed. (First floor and Second floor) Findings include: Review of the facility policy titled, Grievances/Complaints, Filing with a revision date of April 2017 states, Policy Statement- Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). Further review of the facility policy revealed, Policy Interpretation and Implementation .5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. 13. If the grievance was filed anonymously, the grievance officer will inform the resident that a grievance has been anonymously filed on his or her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and interviews with staff and residents, it was determined that the facility did not ensure that dietary preferences were honored for three of 23 residents (Residents R72, R97, R65). Findings include: During a group interview on October 2, 2024, at 10:00 a.m., Resident R97 stated that he had told facility staff multiple times that he did not like ravioli or egg salad, but that they kept serving those items to him. During this same interview, Resident R72 stated that he was on a no-salt diet, but that the food they served him was too salty. Review of clinical documentation revealed that Resident R72 was admitted to the facility on [DATE]. Review of his most recent MDS (a periodic assessment of resident care needs) completed on August 19, 2024, revealed that in section C- Cognitive Patterns, the resident had been assessed to have a BIMS (Brief Interview for Mental Status, an assessment which measures short term memory and orientation to person, place, time, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility documents, and interview with staff and residents, it was determined that the facility did not ensure that meals and snacks were provided at appropriate times for two of two floors observed (First and Second floor). Findings include: Review of the list of facility mealtimes revealed that lunch in the Second floor dining room is scheduled to be served at 12:00 p.m. every day. Observations of the Second floor dining conducted on September 30, 2024, at 11:45 a.m. revealed that residents were seated in the dining room, some with clothing protectors already in place. Continued observation revealed that the cart containing the lunch trays was delivered at 1:29 p.m. Staff began to distribute the trays at that time. The final tray was delivered at 1:48 p.m. Observations of the Second floor dining room conducted on October 2, 2024, at 12:07 p.m. revealed that again residents were seated in the dining room, some with clothing protectors in place. The cart of lunch trays was delivered to the floor at 1:28 p.m., with the final tray served at 1:35 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review clinical records, review of facility documentation, and interviews with staff, it was determined that the facility failed to inform residents of their rights, rules, regulations, and responsibilities prior to and/or upon the resident's admission for three out of twenty-three residents reviewed. (Residents R29, R74, R317) Findings Include: Resident Council held on October 2, 2024 at 10:00 a.m. with ten awake, alert, and oriented residents revealed that when asked about resident rights being reviewed there were l residents stated they have not received a copy or had a copy reviewed with them. Review of Resident R29's clinical record reveled the resident was admitted on [DATE] and the resident's admission packet was not reviewed with the resident until August 21, 2024. Interview held with Admissions staff, Employee E3 on October 3, 2024 at 12:20 p.m. revealed Resident R29 was admitted on a Friday, and that she does not recall why the admission paperwork was not signed on that Friday. Employee E3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documentation, clinical record review, and interviews with staff, it was determined that the facility failed to provide copies of medical records as requested in a timely manner for one of one residents reviewed for medical record request (Resident R317). Findings include: Review of a Medical Record and [NAME] Request letter provided by Employee E1 the Nursing Home Administrator stated the next of kin was requesting medical records from 1/1/2021 to 10/31/2022 in an electric format only. Interview on October 2, 2024, at 1:13 p.m. Employee E1, the Nursing Home Administrator (NHA) stated that he received the request for medical records for Resident R317 on May 29, 2024. The NHA stated that the request was never fulfilled and that the records have not been sent out to the requestor. The NHA explained that he lost track of the request due to him needing to request the ability to send over the documents through the facility's corporate quality assurance team. Employee E1, the NHA stated he needed to transfer the information onto an external disk which was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, observation, review of clinical records, and interview with staff, it was determined that the facility failed to ensure feeding assistance was provided for one of twenty-three residents reviewed. (Resident R80) Findings Include: Review of facility documentation titled, Facility Food Service Program states, Policy and Procedure: Red/Yellow Program- the facility has developed a program to identify residents more easily at mealtime who are at nutritional risk and is in need of supervision, partial assist, or extensive feeding assistance during mealtimes. The following outlines the procedure for flagging those residents. 1. The residents on the list will receive a RED sticker or YELLOW sticker on their meal tags in addition to their usual white napkin. Red Program-Extensive Feeding assistance. Observation of Resident R80 during the lunch meal on September 30, 2024 at 12:53 p.m. revealed the resident was seated in the dining room with two other residents at her table. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure appropriate orders, care plan, and maintenance related to respiratory care were in place for one of twenty-three resident's reviewed. (Resident R83). Findings Include: Review of facility policy titled, CPAP/BiPAP Support with a revision date of March 2015 states, Purpose- 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. Observation on September 30, 2024 at 10:30 a.m. of Resident R83 in their room revealed the resident had a a CPAP machine bedside. Interview held with Resident R83 revealed the resident stated that the machine was a non-invasive CPAP machine that she had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 23 residents reviewed (Resident R21). Findings include: Review of clinical documentation for Resident R21 revealed that she was admitted to the facility on [DATE], and had diagnoses of , dementia, diverticulitis of the large intestine (a condition wherein abnormal pouches which protrude off of the intestine, known as diverticulum, become inflamed, causing pain and disruption of normal bowel function), and type 2 diabetes. Review of the resident's weight documentation revealed that on August 9, 2024, the resident weighed 225 pounds and on September 20, 2024, the resident weighed 199 pounds. This was an 11.56 % weight loss in less than three months, which met the criteria of a significant weight loss. Continued review of her clinical documentation revealed a Nutrition Evaluation from the Registered Dietitian, Employee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record and interview with staff, it was determined facility did not ensure that medical records were complete and accurately documented in accordance with accepted professional standards of for two of 23 residents reviewed (Residents R6 and R58) Findings include: Review of clinical records for Resident R6 revealed that he was admitted to the facility on [DATE], and had diagnoses of acute osteomyelitis (bone infection) of the left ankle and foot, open wound of the left foot, and peripheral vascular disease (a condition in which blood vessels outside of the brain and heart narrow, spasm, or become blocked; this can lead to reduced blood flow and potential tissue damage). Continued review revealed a wound care consultation note written by Employee E12, Registered Nurse Practitioner and wound specialist, written on September 30, 2024. The note stated, the resident has a treatment change .reference the recommended orders for updated treatments . Recommend changing treatment to left heel to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for two of two units observed. (Unit One and Unit Two) Findings Include: Review of facility policy titled, Storage of Medication with a revision date of April 2007 states, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrgiators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. During observation of unit one on February 27, 2024 at 10:50 a.m. revealed the medication cart used by Licensed Nurse, Employee E6 outside room [ROOM NUMBER] on unit one was left unattended and unlocked. Licensed Nurse, Employee E6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of resident's medical information on two or two nursing units. (Unit one and Unit Two) Findings Include: Review of facility policy titled, Resident Rights last revised December 2016 states, Employees shall treat all residents with kindness, respect, and dignity. The unauthorized release, access, or disclosure of resident information in prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPPA Compliance Officer. During observation of unit one on February 27, 2024 at 10:50 a.m. revealed the medication cart used by Licensed Nurse, Employee E6 outside room [ROOM NUMBER] on unit one was left unattended with the computer screen open with identifiable information so any passerby could see…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to dining for two of two dining rooms observed. (First floor and second floor dining rooms.) Findings include: Observations of lunch dining on the first-floor dining room, on December 12, 2023, at 12:32 p.m. revealed the following: A table with four residents seated; two residents were served a meal at 12:36 p.m. and consumed 100% of their meal meanwhile two other residents were waiting to be served a meal. Resident R109 stated, I don't know why I always get my food last. Further observations revealed the residents' meal tray arrived at 12:54 p.m. Observations of lunch dining on the second-floor dining room, on December 13, 2023, at 12: 19 p.m. revealed the following: 16 out of 16 residents were dressed in aprons without permission. A table with four residents seated; one resident was served a meal at 12:34 p.m.; another resident was served a meal at 12:50 p.m.; and two residents were served at 12:55 p.m. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: A review of undated facility policy titled, Labeling and Dating Inservice, indicated that all foods should be dated upon receipt before being stored. Food labels must include the item name; the date of preparation/receipt/removal from freezer; and use by date . A tour of the Food Service Department was conducted on December 12, 2023, at 9:35 a.m. with Employee E5, Food Service Director (FSD), revealed the following concerns: Observations throughout the foodservice department, including the main kitchen area, dish room, pantry, and other common areas revealed the floors were dirty with food crumbs, crevices in the floor tile were filled with debris. Observations of the walk-in refrigerator revealed the following items were opened, unlabeled, and undated: sour cream; Swiss cheese, mozzarella cheese; two pork sausage bulk links; turkey roast; and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of clinical records, facility policies and facility documentation, and interviews with staff, it was determined that the facility failed to review and revise a comprehensive person-centered plan of care in a timely manner, for one of 26 clinical records reviewed (Residents R19). Findings include: Review of facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Observations conducted on the first-floor nursing unit on December 12, 2023, at 1:17 p.m. revealed that Resident R19 had dentures placed on her table stand. Interview with the resident at the time of the observation revealed that Resident R19's dentures are no longer fitting, and that she has had a hard time chewing for months. Review of Resident R19's dental records dated, May 30, 2023, revealed that Resident R19's edentulous ridge (the raised part of the alveolar process after teeth have been removed) was moderate and that she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews with staff and review of the clinical record, it was determined that the facility failed to ensure that that residents received treatment and care in accordance with professional standards of practice related to failing to ensure that recommendations from the resident's cardiologist recommendations were followed for one out of 26 residents reviewed (Resident R24). Findings include: Review of the December 2023 physician orders for Resident R24 indicated that the resident was admitted into the facility on December 23, 2022, and had diagnoses of diabetes (a condition that related to an individual having blood sugar that is too high); hypertension (high blood pressure) and difficulty in walking. Review of the resident's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 1, 2023 indicated that the resident was cognitively intact. Review of a consultation dated November 28, 2023, from the resident's cardiologist appointment on the referenced day, documented that the resident had a diagnosis of chronic systolic heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, review of facility policy, and review of clinical records, it was determined that the facility failed to follow physician orders for oxygen administration for two of 26 residents observed. (Resident R79 and Resident R42). Findings include: Review of facility policy on Oxygen Administration revealed that under section Purpose revealed that the purpose of this procedure is to provide guidelines for safe oxygen administration. Under section Steps in the Procedure# 8. Turn on the Oxygen. Unless otherwise ordered, start the flow of Oxygen at the rate of 2 to 3 liters per minute. #10. Adjust the flow of Oxygen device so that it is comfortable for the resident and proper flow of Oxygen is being administered. Review of Resident R79's physician's order dated February 9, 2023, revealed an order for Oxygen orders 2 liters/minute, via nasal canula, continuous oxygen every shift. Observation of Resident R79 conducted on December 12, 2023, at 10:18 am during the tour of the second floor revealed that Resident R79 was on oxygen concentrator via nasal cannula…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility documents, observations, and interviews with staff, it was determined that the facility did not establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for one resident and failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R86 and Resident R4). Findings include: Review of facility policy on controlled substances revealed that under section Policy Statement, the facility shall comply with all laws and regulations and other requirements related to storage, disposal and documentation of scheduled II and another controlled substances. Under section Policy Interpretation and Implementation, #3. Controlled substances must be, counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. #4. If the count is correct, an individual resident controls substance record must be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, review of facility documents and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication rooms observed (second floor medication room). Findings include: Review of facility policy on controlled substances revealed that under section Policy Statement, the facility shall comply with all laws and regulations and other requirements related to storage, disposal and documentation of scheduled II and another controlled substances. Under section Policy Interpretation and Implementation, #3. Controlled substances must be, counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. #4. If the count is correct, an individual resident controls substance record must be made for each resident who will be receiving a controlled substance. Do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure therapeutic diets were served per physician orders for three of 26 residents reviewed (Residents R36, R31 and R71). Findings include: A review of facility policy titled, Therapeutic Diets, revised October 2017, indicted that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care. Review of Resident R36's clinical records revealed a physician order dated, June 26, 2023, for a therapeutic diet, Puree texture, nectar consistency. A review of Resident R36's Speech Language Pathology discharge recommendations dated, September 14, 2023, revealed Resident R36 was recommended Nectar Thick Liquids. A review of Resident R31's Speech Language Pathology discharge recommendations dated, October 23, 2023, Resident R31 was recommended Nectar Thick Liquids. A review of Resident R31's clinical records revealed a physician's order dated, November 3, 2023, for a therapeutic diet, pureed texture, Nectar consistency.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed properly. Findings include: An initial tour of the Food Service Department conducted on December 12, 2023, at approximately 9:35 a.m. with the Food Service Director (FSD), Employee E5, revealed the following concerns in the outdoor garbage and receiving area: Debris and plastics (cups, lids, dirty gloves, condiment packets, saran wrap) was observed around the trashcan area. Observations revealed piles of spoiled fruit droppings (premature shedding of fruit from a tree before fully ripe) throughout the receiving and garbage area with unpleasant odors, which created an unsafe and unsanitary environment in the main food receiving area. Interview on December 12, 2023, at approximately 9:45 a.m. with the FSD confirmed the above-mentioned findings and acknowledged that the current receiving, and dumpster area was unsafe and allowed pest harborage (conditions or place where pests can obtain water or food, nest, or obtain shelter). 29 Pa. Code 201.18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of the facility's infection control policies and procedures and clinical records and staff interview, it was determined the facility failed to consistently implement an antibiotic stewardship program and maintain a system to effectively monitor antibiotic usage for one of six sampled residents for unnecessary medication usage (Resident R86). Findings include: A review of facility policy entitled Infection Prevention and Control Plan last reviewed October 2023, revealed The facility assures there is an infection control program that is effective for investigating, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor, analyze, and make recommendations. The data will be submitted to the AQPI committee monthly. Review of infection control protocols submitted by the facility during the survey revealed that the facility followed McGeer's Criteria to evaluate and monitor the use the use of antibiotics. Review of physician orders for Resident R86 dated November 18, 2023, revealed medication orders for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.