Rittenhouse Post Acute

Inspectors wroteBased on review of facility documents, clinical reviews and staff interviews, it was determined that the facility failed to investigation for an allegation of possible staff to resident abuse for one of 12 residents (Resident R41).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to develop a comprehensive care plan with interventions related to paired care, adaptive utensils, medication refusals, a neck collar, and CPAP machine for two of 12 residents reviewed (Residents R41 and R36).

Inspectors wroteBased on surveyor observation, clinical record review, and interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards related to medication administration for two of 12 residents reviewed (Resident R41, R65). Findings Include: Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE] with diagnoses of Radiculopathy, cervical region (pinched neck nerve); spondylosis without myelopathy or radiculopathy, cervical region (neck arthritis); dysphagia (swallowing difficulty); atelectasis (partial lung collapse); adjustment disorder with depressed mood (situational depression); need for assistance with personal care (daily care needs); cognitive communication deficit (thinking/communication difficulty); spinal stenosis with neurogenic claudication (narrowed spinal canal); [...]

Inspectors wroteBased on a review of clinical records, and interviews with residents, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming, nail and shaving for two of the 12 residents reviewed. (Residents R41 and R40)

Inspectors wroteBased on a review of the facility's nursing staff competencies and skills required to provide resident care, the facility failed to ensure complete competency documentation for two of the two nursing staff reviewed. (Employees E13 and E14) Findings Included: Review of Facility nursing staff competency records revealed that Employee E13, Registered Nurse was hired on July 9, 2025. No documented evidence of competencies related to Medication Administration, Catheter care or pain assessments. Review of Facility nursing staff competency records revealed that Employee E14, Registered Nurse was hired on December 23, 2025. No documented evidence of competencies related to Medication Administration, Catheter care or pain assessments. [...]

Inspectors wroteBased on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months (May 2025 through May 20, 2026).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a plan of care was related to the diagnosis of seizure for one of two residents reviewed. (Resident R1)

Inspectors wroteBased on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure that medication was deliver timely from the pharmacy to be administer to the resident as ordered by the physician for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies and documentation, clinical records, and interviews with staff, it was determined the facility failed to ensure Resident R65 who required supervision/assistance with ambulation was accompanied by an escort during a medical appointment outside of the facility. This failure resulted in actual harm to Resident R65 who sustained a fall and fracture of nasal bone for one of four residents reviewed. (Resident R65)

Inspectors wroteBased on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-Coverage (NOMNC) for one of three residents reviewed (Resident R66).

Inspectors wroteBased on observations, review of facility policy, review of clinical records, and staff in our view, it was determined that the facility failed to develop and implement a person center and comprehensive care plan related to resident's nutritional needs and weight loss for one resident. (Resident R1)

Inspectors wroteBased on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to monitor, implement and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutrition for two of sixteen resident records reviewed. (Residents R61 and Resident R1)

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of residents for two of two residents with diagnosis of PTSD (post-traumatic stress disorder). (Resident R60 and Resident R63)

Inspectors wroteBased on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure one resident was free from significant medication error for 1 of 3 resident reviewed. (Resident R1)

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that drugs ad biologicals are stored in a safe/secure environment in accordance with professional standards for one of one medication room and for one of sixteen residents observed. (Resident R60)

Inspectors wroteBased on review of personnel files, review of facility documentation, and staff interview, it was determined that the facility failed to employ a qualified registered dietitian.

Inspectors wroteBased on staff interviews and a review of employee personnel records, it was determined that the facility's activities program was not directed by a qualified professional as required.

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on review of facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to establish Enhanced Barrier Precautions for five of six residents reviewed (Resident 62, Resident 63, Resident 65, Resident 112, Resident 116).

Inspectors wroteBased on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for one of one records reviewed related to hospital transfers (Residents R10).

Inspectors wroteBased on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to ensure that a comprehensive assessment was conducted with direct observation and communication with resident as required for one of eight residents reviewed. (Resident R62) Findings Include: Review of RAI (Resident Assessment Instrument) manual Section J, under the tile of Should Pain Assessment Interview Be Conducted? revealed guidelines for pain assessment which indicated Health-related Quality of Life o Most residents who are capable of communicating can answer questions about how they feel. o Obtaining information about pain directly from the resident, sometimes called hearing the resident's voice, is more reliable and accurate than observation alone for identifying pain. [...]

Inspectors wroteBased on the review of clinical records and staff interviews, it was determined that the facility failed to complete comprehensive assessments that accurately reflected the resident status for one of eight residents reviewed (Resident R62).

Inspectors wroteBased on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for one of three residents reviewed (Resident R65, R62 and R64).

Inspectors wroteBased on the review of clinical records, interviews with staff and resident, it was determined that 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 one of eight residents reviewed. (Resident R65) Findings Include: Interview with Resident R65 on August 26, 2024, at 10:00 a.m. stated she was admitted to the facility two weeks ago from the hospital after a back surgery. Resident stated she had surgical incision to her back which was hard for her to monitor and care. Resident stated facility staff did not monitor or cleaned the incision for few days after her admission. Resident stated after few days she had to call the physician and complained to the staff to get the treatment in place. Resident also stated the incision eventually became infected and she was on antibiotics. [...]

Inspectors wroteBased on the review of facility documentation, review of clinical records, staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for one of eight residents reviewed. (Resident R64)

Inspectors wroteBased on review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist or their designee attended a quarterly Quality Assurance Process Improvement (QAPI) committee meetings for four of four quarters reviewed (October 2023 through July 2024). Findings Include: A review of QAPI committee meeting attendees list via online web meeting for the month of October 2023, January 2024, April 2024 revealed that it lacked an Infection Preventionist. There was no sign in sheet or QAPI information available for July 2024. Interview with Clinical Administrative staff, Employee E5, on August 28, 2024, at 11:00 a.m. confirmed that there was no Infection Preventionist attended the QAPI meeting for the facility. 28 Pa. Code 201.18 (1)(3) Management.

Inspectors wroteBased on review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure residents were provided food that accommodates resident's allergies for one of 11 residents reviewed. (Resident R66)