The Renaissance at Kessler Park

Inspectors wroteBased on observation, interview, and record review, the facility failed treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 residents (Resident#1) reviewed for resident rights. CNA A failed to feed Resident #1 in a respectful manner on 07/07/26 when she stood over Resident#1 while feeding him and talking with staff in the dining room. This failure could place residents at risk of decline of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 (Kitchen #1) reviewed for food safety in facility's only kitchen. The facility failed to ensure leftover food was labeled, dated, and stored properly in the refrigerator. The facility failed to ensure personal cups were kept in the designated area and not on the prep table. These failures place residents at risk of cross-contamination and foodborne illnesses.

Inspectors wroteBased on interviews and record reviews, the facility failed to (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 for 1 (Resident #1) of 3 residents reviewed for discharge or transfer. The facility failed to provide written notification to Resident #1's RP and Long-term care Ombudsmen. This failure could place residents at risk of improper transfer from the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for 1(Resident #1) of 3 residents reviewed. The facility failed to update Resident #1's care plan to reflect a history of exit seeking behaviors. This failure could place residents at risk of not receiving proper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #10) of 4 residents reviewed for pharmaceutical services. The facility failed to ensure a package of Resident #10's Morphine Sulfate and MS Contin were immediately delivered to facility nursing staff by CNA A. This failure placed all 60 residents at the facility at risk of not receiving the therapy and/or care per provider orders to allow her to attain or maintain her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for two (Resident #1 and Resident #2) of four residents reviewed for infection control. 1. LVN B, LVN D, and CNA A did not wear gowns for PPE for Resident #1 who was on EBP during incontinent care and linen change. 2. The facility did not keep Resident #1 and Resident #2 ' s feeding pump pole free of a brown, thick substance, and a sticky dirt substance on both the poles, and the floor under the poles, while using the poles to feed Resident #1 and Resident #2. These failures affected residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a resident who was unable to carry out ADLs the necessary services to maintain grooming, and personal hygiene for one (Resident #1) of four residents reviewed for ADL care. Resident #1 ' s brief was soiled, and her bedding had a brown ring around her, with a strong ammonia odor, on 06/18/2025. This failure could affect residents by decreasing quality of life and contributing to skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feedings for one (Resident # 1) of two residents reviewed for enteral feedings. 1. The facility failed to ensure Resident #1 was not laid flat in bed while her enteral feeding was still running. This failure placed residents with enteral feedings at risk of aspiration (entering the airways or lungs) and hospitalization. Findings Included: [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure each resident had the right to be free from abuse for four (Residents #1, #2, #3, #4) of 9 residents reviewed for Abuse. 1. The facility staff failed to ensure Resident #1 did not hit Resident #2, which resulted in Resident #2 getting a skin tear to his face in the dining room on 09/14/24. 2. The facility staff failed to ensure Residents #3 did not throw orange juice twice, at Resident #4, which resulted in Resident #4 hitting Resident #3 in the face and causing redness to Resident #3's face, in the dining room on 09/13/24. These failures could place residents at risk of injuries such as fractures, bruising, skin tears, and psychological harm resulting in decreased health and psycho-social well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food safety. The facility failed to use one utensil for each food item served during lunch. This failure could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, the medical record was maintained on each resident that were complete and accurately documented for 1 (Resident #49) of 8 residents records reviewed for treatment documentation. The facility failed to ensure Resident #49's orders for his tracheostomy and tracheostomy care were in the EMR. This failure could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of two residents reviewed for quality of care. The facility failed to call physician for an x-ray order of Resident #1's left wrist and hand in a timely manner, which resulted in delayed treatment for a period of 7 days without treatment. On 06/15/2024, approximately 7:45 AM CNA B reported to RN A, pain and swelling in Resident # 1's left hand. Left hand noted swollen. Resident # 1 revealed difficult to move at wrist, there was swelling and slight reddish bruising. Resident stated she fell on 6/14/24 after breakfast. Resident #1 was able to get herself up. Resident #1 assessed by RN A, DON notified. [...]

Inspectors wroteBased on record review, the facility failed to ensure a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body appoints the administrator who is licensed by the State, where licensing is required for one (Administrator) of one staff reviewed for administrative license. The facility failed to ensure the Administrator's license was current, which expired [DATE]. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 of 63 resident (Resident #1) reviewed for neglect, in that: The facility failed to report the allegation of neglect r/t falls for Resident #1 to the State Agency within required reporting timeframes. This failure placed residents at risk of ongoing neglect.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen tubing was dated. These failures affected residents and placed them at risk of not receiving the needed services for respiratory care.

Inspectors wroteBased on interview and record review the facility failed to allow the resident representative the right to exercise the resident's rights to the extent those rights were delegated to the representative for 1 of 1 resident (Resident #1) reviewed for resident rights. The facility failed to provide Resident #1's medical records, when Resident #1's POA requested them on 02/07/24. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for one (South hall) of two halls reviewed for environment affecting 24 of 66 rooms. The facility failed to ensure the physical layout maximized resident independence and did not pose a safety risk on 2 of the 3 sections of the South hall which affected 24 of 66 rooms. This deficient practice could place residents at risk for falls and/or injury.

Inspectors wroteBased on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices for 1 of 4 residents (Resident # 2) reviewed for quality of care. The facility failed to follow physician orders concerning a non-pressure wound of the left, lower medial (situated in the middle) buttock for Resident # 2. This failure could place residents at risk of delayed treatment of injuries, worsening of injuries, pain and infection. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 15 residents (Resident # 3 and Resident # 4) reviewed for wounds. The facility failed to ensure treatment and documentation of pressure ulcers for Resident # 3 and # 4 and failed to ensure orders from the hospital were correct and accurate for Resident # 4's pressure ulcers upon readmission. This failure could affect the residents, who received pressure ulcer care, by placing them at risk of unnecessary infection and worsening of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 7 residents (Resident #2) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #2. This failure could place residents at risk for not receiving specialized services in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure all PASRR level I residents were provided with an accurate PASRR level I for 2 of 7 (Resident #3 and Resident #4) reviewed for PASRR screening. The facility failed to complete PASRR level 1 screenings for Resident #3 and Resident #4. This failure could place residents at risk of not being evaluated and not receiving specialized services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1 received timely incontinent care. This failure could put residents at risk of impaired skin integrity and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services according to professional standards of maintenance for one (Resident #1) of two residents reviewed for enteral feeding. The facility failed to ensure Resident #1's g-tube syringe (used for flushing a continuous feed g-tube with water before, after, and during medication administration via the g-tube) was exchanged daily for a new syringe. This failure could affect residents by causing infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 for one (Resident #2) of seven residents observed for infection control. CNA C failed to properly execute glove changes and hand hygiene when entering the room of Resident #2, who was on contact isolation for an infection. This failure could place residents at risk for spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident and/or representative had the right to participate in the development and implementation of his or her person-centered plan of care for 4 (Residents #24, #35, #40, and #70) of 10 resident records reviewed for initial care plan meetings and quarterly care plan meetings.

Inspectors wroteBased on observation and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 5 (Residents #2, #52, #10, #16, #22) of 18 residents reviewed for available call systems in 200 South Hall. Staff failed to ensure Resident #2, #52, #10, #16, #22's call cords were within reach. This failure could affect residents who resided on Unit 200 Hall, by placing them at risk for decreased quality of life and a delay in receiving care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents had the right to a clean, comfortable, and homelike environment, for South Hall 200. The facility failed to properly maintain areas in a clean, comfortable, and sanitized environment on South Hall 200 for 14 residents rooms out of 28 resident rooms (Rooms 207, 209, 210, 211, 221, 225, 226, 227, 228, 229, 230, 231, 232, 233).

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 18 (03/11/23, 03/12/23, 03/18/23, 03/19/23, 03/25/23, 03/26/23, 04/01/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/16/23, 04/22/23, 04/23/23, 05/06/23, 05/07/23, 05/21/23 and 06/04/23) of 28 days reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 18 days (Saturdays and Sundays) beginning 03/10/23 until 06/13/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for one staff (MA A) of three staff observed during medication pass for infection control in that: 1. MA A failed to sanitize the B/P cuff and machine between residents. This failure could affect all residents by causing cross contamination and placing them at risk for exposure to a contagious disease, infection, and possible hospitalization. An observation on 06/14/23 at 8:51 AM, revealed MA A greeted Resident #42, let her know what she was going to do. [...]