Phoebe Richland Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Richlandtown, Pennsylvania.
- Location
- 108 South Main Street, Richlandtown, Pennsylvania 18955
- CMS Provider Number
- 395023
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Phoebe Richland Hcc during CMS and state inspections, most recent first.
A resident with heart failure and chronic respiratory failure was unable to access a functioning call bell, as required by their care plan. Observations revealed the call bell was either non-functional or out of reach, and the facility's Administrator confirmed the issue needed repair.
The facility failed to provide necessary adaptive equipment for two residents during meals. One resident with dysphagia and hemiparesis and another with dementia and Parkinson's disease were both served beverages in handled mugs without the required lids, despite care plans and physician orders specifying their use. This oversight could affect their nutritional intake and safety.
The facility failed to maintain food safety and sanitation standards in the Country Inn Dining Room. Dietary staff did not change gloves after handling non-food items, and food temperatures were not consistently monitored. Unsanitary conditions were observed in the kitchen, including dirt and debris under equipment and a brown substance in the microwave.
A refrigerator was improperly plugged into a power strip in the EVS Office, violating NFPA 101 standards. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not comply with construction requirements for a Type V (000) unprotected wood frame building. The building, fully sprinklered, was classified as a two-story structure, exceeding the maximum allowable height by one story. This deficiency was confirmed during a document review and an exit interview with the Administrator and Maintenance Director.
The facility did not maintain required travel distances within smoke compartments, affecting one of seven compartments. A document review revealed that the travel distance in the Area A/Gateway exceeded the 200-foot maximum. This was confirmed in an interview with the Administrator and Maintenance Director.
Failure to Ensure Accessible Call Bell for Resident
Penalty
Summary
The facility failed to ensure that a functioning call bell was accessible for a resident, identified as Resident 14, who was part of a sample of 25 residents. Resident 14 had medical conditions including heart failure, muscle weakness, and chronic respiratory failure, and required assistance from staff for activities of daily living. The resident's care plan included an intervention for staff to ensure that a functioning call bell system was within reach and that the resident should be encouraged to use it. However, on January 28, 2025, the resident was observed in his room, soiled and needing to be changed, and reported that his call bell did not work. When the resident pressed the call bell button, the light outside his room, which was supposed to alert staff, did not activate. Further observations on January 29, 2025, revealed that the resident attempted to reach his call bell to request ice cream, but the call bell button was hanging below the bed and out of reach. The call bell remained in the same inaccessible position during a subsequent observation. In an interview on January 31, 2025, the facility's Administrator acknowledged that the resident's call bell light was not functioning properly and required repair. This deficiency indicates a failure to accommodate the resident's needs and preferences as outlined in the care plan, potentially compromising the resident's ability to communicate needs effectively.
Plan Of Correction
Rounds were made by Assistant Director of Nursing and EVS staff to ensure resident's call bells were functioning and within reach. Resident 14's call bell was replaced and functioning appropriately and placed within reach. Nursing, Community Life, Therapy, and Housekeeping staff will be re-inserviced by Director of Nursing / Designee on ensuring residents have their call bell within reach. Random audits will be completed by Director of Nursing / Designee on ensuring residents have their call bells within reach and that they are appropriately functioning weekly x4, monthly x2. Results of audits will be reviewed by the facility QAA Committee for further recommendations and/or follow-up.
Failure to Provide Adaptive Equipment During Meals
Penalty
Summary
The facility failed to provide necessary adaptive equipment for two residents who required it during meals. Resident 6, who has diagnoses including dysphagia and hemiparesis affecting the right dominant side, was identified as being at risk for nutritional problems. The care plan and a physician's order specified that Resident 6 should receive beverages in handled mugs with lids. However, during a lunch meal observation, it was noted that while Resident 6 was served beverages in handled mugs, the lids were not in place, contrary to the prescribed intervention. Similarly, Resident 24, who has diagnoses including dementia, Parkinson's disease, and muscle weakness, was also identified as being at risk for nutritional problems. The care plan and a physician's order directed that Resident 24 should be provided with a handled mug with a lid during meals. During the same lunch meal observation, it was observed that Resident 24 was served beverages in a handled mug without the lid in place. This oversight indicates a failure to adhere to the prescribed interventions for both residents, potentially impacting their nutritional intake and safety.
Plan Of Correction
Director of Nursing completed an audit of residents with adaptive equipment for meals to ensure ordered equipment is in place. Nursing and Dietary staff will be re-inserviced by Director of Nursing/Designee on ensuring ordered adaptive equipment is in place at mealtime. Random audits will be completed by Director of Nursing / Designee on ensuring residents have their adaptive equipment during meals weekly x4, monthly x2. Results of audits will be reviewed by the facility QAA Committee for further recommendations and/or follow-up.
Food Safety and Sanitation Deficiencies in Dining Room
Penalty
Summary
The facility failed to adhere to food safety requirements during meal service in the Country Inn Dining Room. Observations revealed that dietary employees did not follow proper hygiene protocols, such as changing gloves after handling non-food items or touching personal items like eyeglasses. Specifically, one employee was seen rinsing a knife and picking up paper meal tickets from the ground without changing gloves before serving food. Another employee handled refrigerator and microwave handles and then touched ready-to-eat bread without changing gloves. Additionally, food temperatures were not consistently monitored, as evidenced by an employee reheating chicken broth without taking its temperature before serving. Further observations highlighted unsanitary conditions in the kitchen area. Dirt and debris were found under the steam table and dish machine, where clean dish racks were stored. The microwave had a brown substance on its inner walls and top. During meal service, pureed soup was left on a surface beside the steam table without a hot holding element, and its temperature was not checked before being mixed back into the main soup pan. These actions and conditions demonstrate a failure to maintain food safety and sanitation standards as required by regulations.
Plan Of Correction
The dirt and debris was cleaned by the Dining Manager from under the steam table, dish machine, the wall, and the microwave. Nursing and Dietary staff will be re-inserviced by the Director of Nursing/Designee on heating foods and beverages in the microwave, hand hygiene, and safe serving temperatures. Random audits will be completed by the Director of Dining/Designee on safe and sanitary practices during meals and sanitary food storage and kitchen conditions weekly x4, monthly x2. Results of audits will be reviewed by the facility QAA Committee for further recommendations and/or follow-up.
Improper Use of Power Strip for Refrigerator in EVS Office
Penalty
Summary
The facility was found to be in violation of electrical safety standards as outlined by NFPA 101. During an observation on January 13, 2025, at 9:40 a.m., it was noted that a refrigerator was improperly plugged into a power strip in the Environmental Services (EVS) Office. This action is contrary to the regulations that prohibit the use of power strips for non-patient-care-related electrical equipment (PCREE) in patient care vicinities. The issue was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day.
Plan Of Correction
The power strip was removed and the refrigerator plugged directly into an outlet on 1/13/2025. A review was completed of other Administrative Offices to ensure any refrigerators are plugged directly into a wall outlet. Administrative offices will be checked monthly for the next 3 months by EVS Director / Designee to ensure any refrigerators are plugged directly into a wall outlet and not in a power strip/extension cord. Results will be reported by the EVS Director/Designee to the QAA Committee x 3 months for review and further recommendations.
Non-Compliance with Building Construction Requirements
Penalty
Summary
The facility failed to adhere to the construction requirements for an unprotected wood frame building, specifically a Type V (000) structure. The building, which is fully sprinklered, was classified as a two-story structure, exceeding the maximum allowable height for this construction type by one story. This deficiency was identified during a document review on January 13, 2025, and confirmed during an exit interview with the Administrator and Maintenance Director. The entire building component was affected by this non-compliance with the construction standards.
Excessive Travel Distance in Smoke Compartment
Penalty
Summary
The facility failed to maintain the required travel distances within smoke compartments for fully sprinklered buildings, affecting one of seven smoke compartments. During a document review on January 13, 2025, it was discovered that the travel distance in the Area A/Gateway exceeded the maximum allowable length of 200 feet. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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