Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Phoebe Richland Hcc during CMS and state inspections, most recent first.
A resident with parkinsonism, urinary retention, and hypotension had an indwelling urinary catheter ordered, but was observed sitting in the dining room with the Foley bag uncovered and containing urine while multiple residents and staff were present. The DON confirmed the bag should have been covered when the resident was in the dining room.
The facility failed to ensure MDS assessments accurately reflected the status of two residents. One resident with heart disease, HF, and a stroke history was incorrectly coded as having an indwelling catheter without supporting documentation, and another resident with an artificial urinary opening and dementia was incorrectly coded as having an indwelling catheter and always being incontinent of urine despite bilateral nephrostomy tubes noted in the record. The DON confirmed the MDSs were inaccurate.
Failure to Address Identified Care Areas in Care Plans Two residents had care areas identified in the MDS CAA summary that were not included in their care plans. One resident received daily lorazepam, a psychotropic medication, but the care plan did not address psychotropic drug use. Another resident had an indwelling catheter, but the care plan did not include catheter-related interventions. The DON confirmed the omissions.
Failure to provide ordered ROM care for a resident with stroke-related right-sided paralysis and impaired ROM. The resident had a physician order and OT recommendation for a resting hand splint on the right hand after morning care for contracture management, but during multiple observations the resident was seated and dressed without the splint in place. The Administrator stated the splint should have been applied as ordered.
A resident with dementia, agitation, insomnia, wandering, and a history of falls had repeated nighttime falls after trying to get into bed. Nursing notes described restlessness, anxiety, paranoia, impulsivity, and pacing, and an anti-anxiety med was ineffective. The resident was later found standing near his bed, turned quickly, and fell, striking his head on a dresser.
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.
Uncovered Foley Catheter Bag in Dining Room
Penalty
Summary
Resident 126, who had diagnoses including parkinsonism, urinary retention, and hypotension, had a physician order on February 12, 2026 for an indwelling urinary catheter. During observations on February 17, 2026 from 12:04 p.m. through 12:35 p.m. and on February 18, 2026 from 11:59 a.m. through 12:30 p.m., the resident was seen sitting in a wheelchair in the dining room with the Foley catheter bag uncovered and containing urine while multiple residents and staff were present. In an interview on February 19, 2026 at 10:45 a.m., the DON confirmed that Resident 126 should have been provided with a cover for the catheter bag when in the dining room.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ current status for two sampled residents. Resident 4 had diagnoses including atherosclerotic heart disease, heart failure, and cerebral infarction, but the MDS assessment incorrectly indicated in Section H that the resident had an indwelling catheter, and there was no documented evidence that an indwelling catheter was present during the MDS review period. Resident 28 had diagnoses including an artificial opening of the urinary tract and dementia; a physician note indicated nephrostomy tubes were in place, and the care plan also identified bilateral nephrostomy tubes, but the MDS assessment incorrectly indicated an indwelling catheter and rated the resident as always incontinent of urine. During interview, the DON confirmed that both MDS assessments were inaccurate and that Resident 28’s urinary continence should not have been rated because of the nephrostomy tubes.
Failure to Address Identified Care Areas in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed individual resident needs identified in the comprehensive assessments for two sampled residents. Resident 42 was admitted with diagnoses including displaced right femur fracture, anxiety, and dementia; the MDS CAA summary dated January 27, 2026, noted that psychotropic drug use was to be addressed in the care plan, and the MARs for January and February 2026 showed daily administration of lorazepam, an antianxiety medication classified as a psychotropic drug, but interventions for psychotropic drug use were not included in the care plan. Resident 108 was admitted with diagnoses including atrial fibrillation, neuromuscular dysfunction of the bladder, and urinary retention; the MDS assessment and CAA summary dated January 28, 2026, noted that the resident had an indwelling catheter and that it was to be addressed in the care plan, but interventions for the indwelling catheter were not included in the care plan. During an interview on February 19, 2026, at 1:30 p.m., the DON confirmed that the identified care areas were not addressed in the care plans.
Failure to Apply Ordered Resting Hand Splint
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Clinical record review showed that Resident 7 had diagnoses including a stroke with paralysis on the right side. The Minimum Data Set assessment indicated memory impairment, need for assistance with dressing, and impairment in ROM on both the upper and lower extremities. A physician ordered staff to apply a resting hand splint to the resident’s right hand after morning care, and an occupational therapy discharge summary recommended the same for contracture management, noting the resident tolerated the splint with separator for at least eight hours a day and that the existing orders remained appropriate for staff to apply the splint after morning care and remove it after dinner. However, during multiple observations on February 17, 2026, the resident was dressed and seated in a chair without the resting hand splint on the right hand. The Administrator later stated that the right resting hand splint should have been in place as ordered by the physician and recommended by occupational therapy.
Failure to Supervise a Resident With Dementia and Nighttime Restlessness
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with dementia and behavioral symptoms. Resident 33 was admitted with diagnoses including dementia with agitation, insomnia, traumatic subdural hemorrhage, and anxiety disorder. The resident’s MDS assessment indicated memory impairment, wandering behavior, and a history of falling, and the care plan identified risk for falls and injury due to unawareness of safety needs, dementia, and impaired mobility. Facility documentation showed repeated nighttime falls and escalating restlessness. On January 10, 2026, the resident was found on the floor in his room holding onto the lever of his roommate’s recliner after trying to get into bed. On January 13, 2026, he was again found on the floor in his room after trying to get into bed and was described as likely having terminal restlessness. Social services later documented wandering behavior and cognitive impairment related to dementia, and the resident was moved to a locked dementia unit due to behavior concerns. On February 5 and 6, 2026, nursing notes described increased restlessness, anxiety, insomnia, paranoia, anger, impulsivity, and pacing in a wheelchair, with an anti-anxiety medication noted as ineffective. Early on February 6, the resident refused to lie down until about 2:00 a.m., went to bed around 2:40 a.m., and was then found standing near his bed at 3:17 a.m. stating he needed the bathroom before turning quickly and falling onto his right side, striking his head on the dresser.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richlandtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belle Terrace | 2.8 mi | ★★★★★ | 15 | 0 |
| Quakertown Center | 3 mi | ★★★★★ | 8 | 0 |
| Lifequest Nursing Center | 4 mi | ★★★★★ | 5 | 0 |
| Valley Manor Rehabilitation And Healthcare Center | 5 mi | ★★★★★ | 7 | 0 |
| Weston Rehabilitation & Nursing Center | 6.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.