Pennsylvania Department of Health
RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are 115 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


RENAISSANCE HEALTHCARE & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and a State Licensure Survey, completed on July 17, 2026, it was determined that Renaissance Healthcare & Rehabilitation Center, was not in compliance with the requirements of 42 CFR part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations: Based on observations and interview with staff it was determined that the facility failed to maintain a homelike environment related to dining for one of two floors observed (First Floor). Findings Include: Observation during the lunch meal service on July 15, 2026, at 12:20 p.m., on the first floor revealed residents were served their meals on disposable Styrofoam plates rather than reusable dinnerware. Interview on July 15, 2026, at 12:20 p.m. with the Food Service Director, Employee E7, confirmed the facility did not have enough reusable plates to serve all residents. The food service director employee E7stated the facility had run out of reusable plates and acknowledged additional plates had been ordered. Documentation of the purchased order was provided in the kitchen director stated new plates were expected to arrive the following day The facilities inability to provide an adequate supply of reusable dinnerware resulted in the use of disposable plates during the resident's meal service, demonstrating the facility failed to maintain sufficient essential equipment necessary to support routine dietary operations. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Plan of Correction - To be completed: 08/31/2026

An audit was completed to determine the amount of re-usable plates needed to ensure all residents had one during meal service.

Additional re-usable plates were ordered and received.

Dietary staff will be re-inserviced on ensuring that all residents that are clinically able to have re-usable plates are provided to them during meal service.

Dietary manager or designee will audit re-useable plate supply once per week for 1 month to ensure there is an adequate supply for appropriate residents.

Administrator or designee will review the audits monthly for 1 month. Any adverse findings will be reported to the monthly QAPI meeting for further recommendations.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations: Based upon review of resident records and interviews with staff it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility residents with transfers and discharges for two of 25 resident records reviewed (Resident R9 and R10). Findings include: Resident R9 was admitted to the facility diagnosed with heart disease. Review of clinical records revealed on January 19, 2026, the resident was transferred to the hospital due to a change in condition and abnormal vital signs. Resident R10 was admitted to the facility on November 25, 2025, diagnosed with Malnutrition (lack of proper nutrition) and had a Gastrostomy (an artificial external opening into the stomach, to allow direct delivery of nutrition, fluids, or medications) used for nutrition. Review of Resident R10's clinical record revealed on April 8, 2026, the resident was observed with altered mental status, and was sent to the hospital for further evaluation. Further Review of Resident R10's clinical records revealed on July 4, 2026, the resident had an unplanned transfer to the hospital, diagnosed with pneumonia (lung infection). On July 17, 2026, at 11:30 a.m. an attempt was made to obtain the notices sent to the representative of the Office of the State Long-Term Care Ombudsman. The Nursing Home Administrator replied, "We don't do that." 28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 08/31/2026

An audit will be completed for missing discharge and transfers starting from Oct/2025 to present. Any missing months for admit/discharge/transfer will be sent to the LTC ombudsman.

The Admissions Director will be inserviced on how to send the report for residents that are transferred/admitted/discharged for each month to the LTC Ombudsman monthly.

Admissions Director or designee will send all transfer/admitted/discharged resident reports for each month to the LTC Ombudsman monthly per regulation.

Administrator or designee will review each months report to ensure it is sent to the LTC ombudsman monthly. Any adverse findings will be reported to the monthly QAPI meeting for further recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations: Based on review of facility policy, review of clinical records, review of facility documentation, and staff interview it was determined that the facility failed to review and revise a resident's care plan to address resident care needs for one of 25 residents reviewed (Resident R27). Findings include: Based on facility policy titled "Therapeutic Leave Policy and Procedure" undated, revealed the purpose of this policy is to establish guidelines, criteria, and procedures for residents requesting temporary therapeutic leave from the facility. The policy states that residents have the right to therapeutic leave in accordance with federal and state regulations and the resident's individual plan of care. The policy further states that the facility will facilitate therapeutic leave while ensuring the residents health, safety and continuity of care are maintained. the policy requires that therapeutic leave aligned with the goals of the resident's individual care plan and include advanced notice clinical assessment authorization sign out procedures and return to facility procedure. Review of Resident R27's Minimum Data St (MDS- federally mandated resident assessment and care screening) dated June 25,2026, revealed that Resident R27 was admitted into the facility on October 2, 2025. Resident R27 was assessed with a brief interview for mental status (BIMS - cognitive function assessment) score of 15 indicating he/she is cognitively intact. The MDS indicated resident R27 had no behaviors, including no wandering. Resident R27 utilized a walker and wheelchair for mobility, was independent with eating and oral hygiene, required supervision or setup assistance with several activities of daily living, and required partial to moderate assistance with transfers. Review of Resident R27's clinical record revealed the resident has diagnoses of coronary artery disease (CAD- condition in which narrowed or blocked arteries reduce blood flow to the heart muscle and increase the risk of chest pain and heart attack); hypertension (elevated blood pressure); atrial fibrillation (a-fib, an irregular heart rhythm that increases with risk of blood clots and stroke); asthma (a chronic inflammatory disease of the airways that can cause wheezing, coughing and shortness of breath); depression (a mood disorder that affects a person's emotions, motivation, thinking and daily functioning) and a personal history of pulmonary embolism (previously experienced a blood clot in the lungs). Review of Resident R27's medication regimen included an anti-depressant, anti-coagulant (blood thinner, which reduces the blood's ability to clot) and diuretic (promotes the elimination of excess fluid and sodium from the body). Review of resident R27's clinical record revealed a physician's order dated October 2nd, 2025, stating the resident may leave the facility for social or therapeutic activities when residents condition permits. Review of resident R27's clinical record and nursing notes revealed a repeated pattern of extended leaves of absences (LOA) that were not anticipated at time of departure and resulted in resident remaining out of the facility beyond expected return date on the following dates: February 5, 2026, March 30, 2026, May 9, 2026. Review of resident R27's comprehensive care plan dated October 4, 2025, revealed the resident's preference for independent leisure activities, with an intervention dated April 1, 2026, that the resident has frequent leave of absences with family. Further review of Resident R27's care plan revealed it did not contain individualized interventions addressing the residents' repeated pattern of extended and unplanned leaves of absence, including occasions when the resident failed to return to the facility as is expected for one or more days. The care plan lacked interventions related to communication with the facility regarding delayed returns, physician notification, medication and treatment management during prolonged absences, assessment of risks associated with missed medications or treatments, or measures to address the residents recurring pattern of not returning as scheduled. 28 Pa. Code 211.10 (c) Resident Care policies 28 Pa. Code 211.12 (d)(5) Nursing Services

Plan of Correction - To be completed: 08/31/2026

R27s Care Plan was updated to reflect her extended LOAs without advance notice.

Current residents in the facility have had their LOAs reviewed for any non-compliant extended LOAs without advance notice. The residents identified with any non-compliant extended LOAs without advance notice have had their care plans reviewed and updated to include non-compliance with not giving advance notice for extended LOAs.

The Director of Staff Development, or designee, has re-inserviced the RN/LPN staff regarding the policy Care Plan Timing and Revision. A focus of the inservice is to ensure that those residents identified with a history of going on extended LOAs without advance notice need to have an updated care plan to reflect this type of history.

Identified residents will be reviewed by the IDT to determine plan and their care plan will reflect the review.

The Director of Nursing, or designee , will randomly audit weekly x 4 and monthly thereafter for 3 months those residents that extend LOAs without advance notice to ensure that a care plan is developed. The results of the audits will be forwarded to the QAPI Committee for further review and recommendations and to determine the need for additional audits.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:
Based on review of facility policy, review of facility documentation, review of clinical records, observation, and staff and resident interviews it was determined that the facility failed to provide necessary treatment and services consistent with professional standards of practice, physician orders, and the comprehensive care plan for two of 25 residents reviewed (Resident R2 and R129).

Findings Include:

Review of the facility's policy titled, "Change in a Resident's Condition or Status" revised January 2026, states that the facility promptly notifies the physician of changes in the resident's medical/mental condition. The same policy indicates that the nurse will record in the resident's medical record relative to changes in the resident's medical/mental condition or status.

Resident R2 was admitted to the facility on November 26, 2025, diagnosed with peripheral vascular disease (narrowed arteries that reduce the flow of blood to your limbs), heart failure, and pulmonary (lung) disease.

Further review revealed Resident R2's care plan for "cardiovascular status" initiated in November 2025 states, "Vital Signs as ordered. Notify physician of any abnormal readings"

Review of Resident R2's hospital records dated March 16, 2026, indicated the resident experienced a fall at the facility and noted the resident with ongoing issues with "labile blood pressures" (sudden, unpredictable changes in blood pressure that can reach concerning levels) and presyncope (feels as if you are going to faint), and occasionally syncope (fainting). The same records indicate that at the time of the fall, on March 15, 2026, the resident felt, "lightheaded and dizzy, lost consciousness, and then fell to the floor." The hospital records noted that the resident's blood pressure normally runs "low" in the morning and "spike" in the afternoon. The hospital records further stated that all medications to treat the resident's high blood pressure were discontinued.

Interview with Resident R2 on July 14, 2026, at 2:00 p.m. stated, "At 2:30 P.M. yesterday I asked my nurse to take my blood pressure because I didn't feel right. I was shaky and felt my hands trembling. I knew it was my blood pressure I was afraid I was going to pass out again. When the nurse, (Employee E13), took my blood pressure it was very high. He wrote down the blood pressures for me. I got even more upset because the nurse wouldn't call the doctor.
Continued interview with Resident R2 on July 14, 2026, revealed the resident also informed his/her physician and cardiologist of the elevated blood pressures.

Observations on July 14, 2026, at 2:00 p.m. with Resident R2 revealed the written note was observed with three sets of blood pressures documented as follows: 186/117, P (pulse) 75, taken standing, 185/117 P 75 and 175/107 while sitting. According to the American Heart Association, this would classify as a hypertensive urgency (Hypertensive Urgency is defined by the American Heart Association and American College of Cardiology as a severe elevation in blood pressure, typically a systolic blood pressure of =180 mmHg and/or diastolic blood pressure of =120 mmHg, without evidence of acute target organ damage), the highest risk for life-threatening complications.

Review of Resident R2's clinical record revealed no documented evidence the blood pressures were documented in the resident's clinical record and revealed no documented evidence a progress note was written to document the findings of the assessment.

Interview with Resident R2's nurse, Employee E13 on July 15, 2026, at 11:00 a.m. confirmed the above incident with Resident R2's. The nurse, Employee E13, confirmed Resident R2 told him he/she did not feel well, and agreed the resident didn't look well and appeared "shaky". The nurse, Employee E13, confirmed all three high blood pressures were not documented in the resident's chart nor was the physician made aware. When asked, the nurse explained, "Resident R2's blood pressure wasn't high in the morning (documented that morning at 8:30 a.m. 128 / 72) and that the resident "doesn't have high blood pressure, because he/she wasn't on any medication".

Review of Resident R2's physician note dated, July 15, 2026, stated that Resident R2 was seen by cardiology and amlodipine 2.5 mg (a medication for high blood pressure) was added because of "a few high blood pressure readings the resident had up to 180's". The physician note continues that Resident R2 described feeling "shaky and flushed" at the time of the high blood pressure readings, and his/her "BP (blood pressure) was checked a few times, and it went to the 180's ... However, when this happened none of these readings have been reported in the EMR (Electronic Medical Record.)" The same physician's note stated, if the systolic blood pressure is greater than 150, consistently, for more than 2 readings "The physician should be called".

Review the facility's policy titled Medication Administration" dated January 2026, revealed medications are to be administered safely, timely, and in coordinates with the prescribers' orders. The policy assigns the director of nursing responsibility for supervising personnel who administer medications and overseeing medication administration practices. The policy further states that medications are to be administered according to prescribed orders and require time frames, with administration times based on residents' clinical needs. Medication errors are to be documented, reported, and review through the facilities quality assurance and performance improvement (QAPI) program to identify opportunities for process improvement and staff education. The policy requires medications to be administered within one hour of the prescribed administration time unless otherwise specified. When a medication is withheld, refused, or administered outside the scheduled time, the individual administrating the medication is required to document the occurrence on the medication administration record in accordance with the facility policy.

Review of the Food and Drug Administration (FDA) approved prescribing information for Catapress TTS - 2 Clonidine transdermal systems application instructions is to apply one patch every seven days on the same day each week. The prescribing information cautions against interruption of clonidine therapy because abrupt discontinuation can result in rebound hypertension.

Review of Resident R129's clinical record revealed a physician order dated March 10, 2026, for Catapress TTS -2 (Clonidine) Transdermal Patch (treats high blood pressure), 0.2 milligrams to be applied once weekly, every Tuesday as ordered by the physician.

Observation on Wednesday July 15, 2026, during medication administration revealed Resident R129 did not have the prescribed clonidine transdermal patch in place. Observation of Resident R129's skin confirmed no patch was present.

Review of Resident R129's medication administration record (MAR) revealed the facility documented that the previously applied patch was removed on Tuesday July 14, 2026, at 6:59 a.m., and a new clonidine transdermal patch was applied at 9:00 a.m. that same day, Tuesday July 14, 2026.

Interview on July 15, 2026, with licensed nurse, Employee E5, confirmed he/she was responsible for administering the clonidine transdermal patch on July 14, 2026. Licensed nurse, Employee E5, acknowledged that although the MAR documented that the patch had been applied on July 14th, the medication was not administered because the patch was not unavailable.

Continued interview with licensed nurse, Employee E5, on July 15, 2026, revealed he/she applied the patch when it became available on July 15, 2026. Licensed nurse, Employee E5, confirmed that the medication was administered late, confirmed physician was not made aware of the missed administration yesterday, and further confirmed it was not accurately documented in the medication administration record.

Interview with Director of Nursing, Employee E2, confirmed Resident R129's prescribed clonidine patch was not administered as ordered.

28 Pa. Code 211.9 (a)(1) Pharmacy Services

28 Pa. Code 211.12(d)(5) Nursing Services

Plan of Correction - To be completed: 08/31/2026

There is no opportunity to retroactively address the cited area for R2. R2 was seen by his cardiologist within 24hours of the elevated Blood Pressures. R129 was given the transdermal patch the next day and physician was notified.
Potentially any resident with an abnormally elevated BP could be impacted if his/her PCP is not promptly notified.

An audit was completed for all residents with an abnormally elevated BP according to their plan of care. The physician was notified for any identified residents.

Staff Development Nurse or designee will re-inservice RN/LPN staff regarding the importance of notifying the resident's PCP for any abnormally elevated BP above the resident's usual PCC trend and documenting.

The ADON or designee will conduct audits of residents with abnormally elevated BPs to ensure that their PCP was informed and any orders received/implemented. The audits will be conducted weekly x 4 weeks then monthly for 3 months.

The DON or designee will monitor the audit results and report at the monthly QAPI meeting. The results of these reviews will be reported to QAPI for further recommendations as needed.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations: Based on review of clinical records and interviews with resident and staff, it was determined that the facility failed to provide treatment/services to maintain or improve range of motion/mobility for one of 25 residents reviewed (Resident R34). Findings include: Review of Resident R34 clinical record revealed the resident was admitted on February 14, 2025, diagnosed with orthopedic care following a surgical amputation and acquired absence of the bilateral toes. Interview with Resident R34 on July 14, 2026, at 11:00 a.m. indicated he/she is no longer receives restorative services (refers to interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). The resident stated he/she used to receive the services, but it just stopped. Review of Resident R34's discharge therapy instructions revealed programs for restorative range of motion and transfers were established since May 2025. Review of Resident R34's care plan revealed the care plan was reviewed and revised on July 2, 2026, for the resident to continue restorative therapy. Further review of Resident R34 clinical records revealed no documented evidence the resident was receiving the service. On July 17, 2026, at 3:27 p.m. during an interview with Employee E12 confirmed Resident R34 does not receive the service. 28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 08/31/2026

There is not opportunity to retroactively address the cited area for R34.

R34 will be screened by therapy for potential therapy evaluation.

An audit was completed by the therapy department to determine which residents needed a restorative program vs a maintenance program. Identified residents had their medical record updated to reflect which program they are on.

Staff Development or designee will complete education for nursing staff regarding completion of Restorative therapy or maintenance program and to update the medical record to reflect the appropriate program and if the program needs to be discontinued or resumed. Education will include: care planning, documentation in POC/task and documentation of resident refusals.

The DON or designee will conduct audits for residents on restorative therapy or maintenance program to ensure a care plan and task is in place and documentation completed. The audits will be conducted weekly x 4 weeks then monthly for 3 months. The DON or designee will collect and monitor the audit results and report at the monthly QAPI meeting. The results of these reviews will be reported to QAPI for further recommendations as needed.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations: Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization related to a diagnosis of Post Traumatic Stress Disorder (PTSD) for two of two residents reviewed (Resident R27 and R12). Findings include: Review of facility policy titled "Trauma Informed Care and Culturally Competent Care" dated January 2026, defines trauma as an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening that results in lasting adverse effects on the individual's mental, physical, social, emotional, spiritual well-being, or overall functioning. The policy further defines trauma informed care as an approach to providing care that recognizes, understands, and responds to the effects of trauma. the policy stated that trauma informed care requires staff to recognize the prevalence, signs, and symptoms of trauma and incorporate the knowledge into resident assessments, individualized care plans, facility policies, procedures, and care practices to minimize the risk of re traumatization and provide personal center person-centered care. The purpose of this policy is to ensure staff provides care in accordance with professional standards of practice by recognizing and addressing the needs of trauma survivors while minimizing the risk of re-traumatization. The policy states that all staff are to receive education on trauma-informed care and care should be based on evidence-based trauma informed and resilience-oriented practices. Further review of facility policy "Trauma Informed Care and Culturally Competent Care" requires the facility to assess residents for trauma related needs as a part of the assessment process, recognize that trauma triggers are highly individualized identify and minimize exposure to potential triggers, and develop individualized, person-centered care plans in collaboration with the resident and when appropriate the resident's family or representative. The policy also emphasizes incorporating residents' cultural preferences, language needs, value and past trauma into care planning, promoting safety, trust, collaboration, empowerment and respect and providing staff education and community resources to support implementation of trauma informed care practices. Review of resident R27's comprehensive care plan dated October 3, 2025, revealed Resident R27 has aproblem of potential and or altered mood state related to depression and Post Traumatic Stress Disorder (PTSD). Interventions included administering prescribed psychotropic medications, encouraging visitation, socialization and activities of residents choice, engaging the resident in discussions that promote self-worth, monitoring for gradual douche reduction when appropriate, moderate monitoring the effectiveness and side effects of medication, obtaining psychology and psychiatry consultations as needed, and having a social service provide support and encourage the residents to express feelings as needed. Further review revealed of Resident R27's care plan revealed no documented evidence it contained individualized, trauma informed interventions specific to the resident R27's diagnosis of post-traumatic stress disorder (PTSD). The care plan did not identify the residents known trauma history, individualized trauma triggers, strategies to minimize re-traumatization, resident specific coping mechanisms, environmental modifications, staff approaches to care, where interventions to address behaviors or emotional responses associate with PTSD. The care plan did not reflect implementation of the facility's trauma informed care policy which requires individualized assessment identification of trauma related triggers and development of person-centered interventions to address the unique needs of residents with a history of trauma. Review of Resident R12's comprehensive care plan dated June 29, 2026, revealed Resident R12 has a problem of potential and or altered mood state related to post traumatic stress disorder (PTSD). The care plan interventions included encourage visitation, socialization, and activities of the resident R12's choice; engaging the resident and topics of interest that promote well-being; obtaining psychology and psychiatry consultations is needed; and having social services provide support and encourage the resident to express feelings of need. Further review revealed the care plan did not include individual trauma informed intervention specific to the resident R12's diagnosis of PTSD. The care plan lacked resident specific interventions addressing trauma history commonly known triggers, strategies to prevent re-traumatization, individually coping techniques, staff approached the care, environmental modifications, or other personal centered interventions consistent with the facilities trauma informed care policy. 28 Pa. Code 211.10 (c) Resident Care Policies 28 Pa. Code 211.12 (d)(5) Nursing Services

Plan of Correction - To be completed: 08/31/2026

There is no opportunity to retroactively address the R12 and R27s care plans to include PTSD. R27 and R12s care plans were updated to reflect past life trauma have a corresponding comprehensive person centered care plan developed/initiated.

Social Services will be re-inserviced to
reflect past life trauma including PTSD have a corresponding comprehensive person centered care plan developed/initiated.

An audit will be completed for residents with a diagnosis of PTSD and/or past life trauma. Identified residents will have have a corresponding comprehensive person centered care plan developed/initiated regarding past life trauma and PTSD.

The DON or designee will conduct audits for all residents whose admission/readmission evaluation indicates PTSD or past life trauma. The audits will be conducted weekly x 4 weeks then monthly for 3 months. The DON or designee will collect and monitor the audit results and report at the monthly QAPI meeting. The results of these reviews will be reported to QAPI for further recommendations as needed.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations: Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for one of two floors (First Floor). Findings include: Review of the facilities policy titled "Meal Distribution Policy" last revised February of 2023, revealed meals are to be transported to resident dining locations in the manner that ensures proper temperature maintenance, protects against contamination, and provides timely and accurate meal delivery. the policy further states that all food items are to be transported properly to maintain appropriate temperatures and that nursing staff are responsible for verifying meal accuracy and timely delivery. Review of standards for food service safety revealed hot foods should be held at 135 degrees Fahrenheit or greater. Interview with Resident R2 on July 14, 2026, at 2:00 p.m. revealed the resident attends food committee meetings and complaints brought up by the residents include that the food is always cold, tasteless, or too many spices. Resident R2 stated the residents complain about the food, but the facility doesn't do anything about it and nothing changes. Review of the facility documentation dated July 15, 2026, revealed breakfast items were held on the steam table, in the main kitchen, at acceptable temperatures for food service safety prior to meal service. Review of facility documentation dated July 15, 2026, revealed the following temperatures were recorded of the breakfast food items prior to meal service that were held in the steam table: Oatmeal recorded at 175 degrees Fahrenheit, and scrambled eggs recorded at 142 degrees Fahrenheit. Observation of breakfast meal service on July 15, 2026, revealed resident meal trays are plated via tray line in the main kitchen and delivered to the nursing units in enclosed food carts where they are then hand delivered to each resident. Observations on July 15, 2026, revealed it took approximately 25 minutes for staff to pass resident meal trays once the food cart was delivered to the unit. A test tray was conducted on July 15, 2026, on the first-floor nursing unit during the breakfast meal service. Twenty-five minutes after the delivery of the food truck to the unit, the final meals were served and a test tray was completed which revealed the following: scrambled eggs measured 100 degrees Fahrenheit, and the oatmeal measured 104 degrees F demonstrating a significant loss in temperature from the documented holding temperatures in the kitchen. Foods were deemed not palatable for temperature. Interview with kitchen director at time of observation confirmed the delays and meal distribution process contributed to food being served at reduced temperatures. The facility failed to ensure meals were transported and served in a timely manner to maintain palatable food temperatures. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Plan of Correction - To be completed: 08/31/2026

Meal Service times were reviewed to ensure dietary and nursing had the same time frames.

Dietary staff will be re-inserviced on meal delivery times. Nursing staff will be re-inserviced on meal delivery times. The focus of the education is to ensure that meals are delivered timely and to have meals served at the appropriate temperature per regulation.

Dietary Manager or designee will complete an audit (3 times Weekly) to determine that meals are delivered timely based on Meal Service Times to ensure that residents receive meals timely and at appropriate temperature per regulation.

The audit will be completed for 60 days.
Administrator or designee will review the audits for compliance. Any adverse findings will be reported to the monthly QAPI meeting for further recommendations.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations: Based on review of facility policy, review of clinical records, and interview with staff and residents it was determined that the facility failed to maintain complete and accurate medical records for two of 25 residents reviewed (Resident R2 and R129). Findings include: Review of the facility policy titled, "Charting and Documentation", revised January 2026, states, "Any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care". Review of Resident R2's clinical record revealed the resident was admitted to the facility on November 26, 2025, and has diagnoses of peripheral vascular disease, heart failure, and pulmonary (lung) disease. Review of Resident R2's physician orders dated April 8, 2026, instructed the resident to wear a heart monitor for 30 days which was completed on May 8, 2026.Further review of Resident R2's physician orders contained an active order for nursing to replace the heart monitor leads every 48 hours though the heart monitor was no longer an active order. Review of the Electronic medication administration (EMAR) report revealed nursing continued to report the leads were still being replaced every 48 hours. Interview on July 15, 2026, at 10:00 a.m. with Licensed Practical Nurse, Employee E14, confirmed Resident R2's heart monitor was no longer in use. Interview with Resident R2 on July 14, 2026, at 2:00 p.m. stated, he/she asked his nurse to take his blood pressure because he did not feel well and the blood pressures were as high as 186/117. According to the American Heart Association a reading this high would be classified as a hypertensive crisis, the highest risk for a life -threatening complications to occur such as a stroke or heart attack. Review of Resident R2 clinical record revealed no evidence the high blood pressures were recorded in the resident's clinical record, nor was a progress note written documenting these findings. Interview with Resident R2's nurse, Employee E13 on July 15, 2026, at 11:00 a.m. confirmed the incident with Resident R2 and stated the resident did not appear well and confirmed the resident told him he didn't. Employee E13 confirmed all three critically high blood pressures were not documented in the resident's chart nor was a progress note written. Review of Resident R129's clinical record revealed a physician order that the resident is prescribed Catapress TTS -2 (Clonidine) Transdermal Patch, 0.2 milligrams to be applied once weekly, every Tuesday as ordered by the physician. Observation on Wednesday July 15, 2026, during medication administration revealed Resident R129 did not have the prescribed clonidine transdermal patch in place. Observation of Resident R129's skin confirmed no patch was present. Review of Resident R129's medication administration record (MAR) revealed the facility documented that the previously applied patch was removed on July 14, 2026, at 6:59 a.m., and a new clonidine transdermal patch was applied at 9:00 a.m. that same day, Tuesday July 14, 2026. Interview on July 15, 2026, with licensed nurse, Employee E5, confirmed he/she was responsible for administering the clonidine transdermal patch on July 14, 2026. Licensed nurse, Employee E5, acknowledged that although the MAR documented that the patch had been applied on July 14th, the medication was not administered because the patch was not unavailable. Interview on July 15, 2025, with licensed nurse, Employee E5, confirmed the medication administration record was inaccurate, and Resident R129's clonidine transdermal patch was not applied on July 14, 2026. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Plan of Correction - To be completed: 08/31/2026

There is no opportunity to retroactively address the cited area for R2. R2 was seen by his cardiologist within 24hours of the elevated Blood Pressures. R129 was given the transdermal patch the next day and physician was notified.

The facility currently does not have any resident on a heart monitor.

Staff Development Nurse will inservice LPN/RN staff for the following: to accurately confirm and document lead placement during heart monitoring, process regarding any delay in medication receipt (medication not available) from pharmacy including notification of physician, and not to document until actually administered.

Staff development nurse will conduct random competency checks for RN/LPN for medication administration and obtaining vital signs weekly for 4 weeks and then monthly for 3 months.

ADON or designee will conduct audits of all residents ordered to have a heart monitor to ensure the leads are being checked as ordered and documented. The audits will be conducted weekly x 4 weeks then monthly for 3 months.

The DON or designee will collect and monitor the audit and competency results and report at the monthly QAPI meeting. The results of these reviews will be reported to QAPI for further recommendations as needed.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Plan of Correction - To be completed: 08/31/2026

The facility cannot retroactively correct the cited area.

An IDT will be established which includes: NHA, DON, and HSKP Director, and Maintenance Director that will complete an assessment and review the facility specific water management program annually going forward.

Maintenance Director or designee will complete water management assessment to include:
Description and flow diagram of the building's water systems.
Completion of CDC toolkit or ASHRAE standards to identify areas and devices where Legionella growth and transmission may occur.

Corrective action measures when control limits are not met
Verify the program is effectively meeting the needs of the facility.
Maintenance Director or designee will audit the water management program monthly for 90 days and then annually thereafter.

Administrator or designee will monitor results of the audit monthly for 90 days and then annually thereafter. Results of the audit will be reported to the monthly QAPI meeting for further recommendations.

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