Renaissance Terrace

In the surveyor’s words

From the most serious findings on record at Renaissance Terrace, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 23, 2023

  Based on review of facility policy, medical record review, review of the facility investigation, weather reports, satellite data, observations and interviews, the facility failed to maintain secure exits (functional door alarms or magnetic locking mechanisms) on 2 of 5 units (C Wing and East Wing) which resulted in the elopement of 1 resident, (Resident #1), an ambulatory, cognitively impaired resident with a history of wandering, of 5 residents reviewed for elopement risks. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when on 5/8/2023 around 7:30 AM, Resident #1 exited the C Wing… […]

• No harm, potential for more than minimal, widespreadF584Sep 20, 2023

  Based on observation and interview, the facility failed to maintain resident rooms and hallways in good repair and in a homelike environment for 18 resident rooms (#23, #8, #21, #20, #27, #100, #30, #9, #101, #18, #5, #32, #31, #102, #103, #104, #13, #38, #10, #105, #106, and #14) of 34 rooms observed of 37 total rooms and 3 of 4 hallways observed which affected 22 residents. The findings include: During an environment tour of 4 Halls and 37 rooms on, 8/28/2023 starting at 10:00 AM and ending at 12:00 PM, the following concerns were observed: room [ROOM NUMBER]A (Resident #23) was observed to have scratched/gouged/scuffed walls and missing paint. room [ROOM NUMBER]B (Resident #8) was observed to have a dirty privacy curtain with circular brown stains. […]

• No harm, potential for more than minimal, widespreadF641Sep 20, 2023

  Based on review of The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 19 residents (Resident #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #23, #27, #30, #31, #32, #37, #38, and #39) for use of side rails, 2 residents (Resident #11 and #23) for dental needs, 2 residents (Resident #11 and #30) for respiratory care, and 1 resident (Resident #21) for significant weight loss of 19 residents reviewed for MDS assessments. […]

• No harm, potential for more than minimal, widespreadF679Sep 20, 2023

  Based on facility policy review, observation, and interview, the facility failed to provide a person-centered activities program which affected 4 of 4 residents (Resident #5, #19, #23, and #36) reviewed for activities which had the potential to affect all 40 residents in the facility. The findings include: Review of the facility policy titled, Life Connection Program, dated 3/2023, showed .Life connections programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident .the life connections program is ongoing and includes facility-organized group activities, independent individual activities, and assisted individual activities .activities are scheduled 7 days per week .scheduled activities are posted on the resident bulletin… […]

• No harm, potential for more than minimal, widespreadF725Sep 20, 2023

  Based on observation, and interview, the facility failed to ensure sufficient staff to provide person-centered activities for 4 of 4 residents (Resident #5, #19, #23, and #36) reviewed for activities and 3 of 4 residents (Resident #5, #19, and #36) reviewed for communal dining service which had the potential to affect all 40 residents present in facility. The findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses to include Chronic Ischemic Heart Disease and Hypothyroidism. […]