Richfield Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richfield, Pennsylvania.
- Location
- 631 Main Street, Richfield, Pennsylvania 17086
- CMS Provider Number
- 396093
- Inspections on file
- 18
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Richfield Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Richfield Healthcare and Rehabilitation Center failed to provide quarterly personal fund statements to two residents, as required by regulations. Interviews revealed that neither Resident 3 nor Resident 13 received statements accounting for their funds, despite the facility managing their social security payments. The business office manager admitted to not providing these statements, and the Nursing Home Administrator confirmed the lack of evidence for issuing them.
The facility failed to maintain food safety standards in the kitchen, with expired items found in a refrigerator and improper storage of scooping utensils in food bins. The dietary manager confirmed these practices were against facility policy, which was discussed with the Nursing Home Administrator and DON.
An LPN at a facility failed to follow proper handwashing techniques during medication administration, using her arm instead of a disposable towel to turn off faucets. This was observed across multiple residents, including one with potential gastrointestinal infection symptoms. The LPN confirmed the improper technique, which was discussed with the facility's administration.
The facility failed to provide the required written notifications for hospital transfers for two residents. For one resident, there was no documentation of notification to the responsible party, and for another, the resident's husband did not receive the notice, as confirmed by a blank signature line. These deficiencies were confirmed through staff interviews and record reviews.
A facility failed to provide a written notice of its bed-hold policy to a resident or the resident's responsible party upon transfer to a hospital. Resident 4 was transferred due to a change in condition, but there was no documentation of the required notice. An interview with a registered nurse supervisor confirmed the absence of this documentation, indicating non-compliance with regulatory requirements.
A facility failed to ensure accurate MDS assessments for a resident who was inaccurately documented as having pneumonia, septicemia, and an MDRO without supporting evidence. These errors persisted across multiple assessments, and the Administrator confirmed the coding errors.
A resident at risk for falls experienced multiple falls due to the facility's failure to implement and document effective interventions. Despite being identified as at risk, the resident's care plan was not updated with necessary interventions after falls occurred. The facility's investigation and interdisciplinary team meeting documentation were insufficient, as confirmed by the DON.
A facility failed to ensure a resident's drug regimen was reviewed by a consultant pharmacist, as the resident was not included in the pharmacist's reports for two months. There was no documentation of irregularities being reported to the attending physician or actions taken, as confirmed by facility staff.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN incorrectly primed an insulin pen with one unit instead of two, leading to an improper dose for a resident. Additionally, the LPN used a plastic cup instead of the provided cap to measure Polyethylene Glycol, resulting in an incorrect dose for another resident. The errors were confirmed during an interview with the LPN.
A facility failed to ensure proper medication labeling for a resident, as observed when an LPN prepared Clonazepam 0.5 mg for administration. The label instructed one tablet twice daily and two at bedtime, conflicting with the physician's order of one tablet twice a day and two in the afternoon. This discrepancy was confirmed by the LPN and discussed with the Nursing Home Administrator and DON.
The facility failed to assist two residents in obtaining routine dental care. One resident had broken and missing teeth with no evidence of routine cleanings since admission, while another resident required tooth extractions but did not receive routine dental services every six months as covered under the State plan. The facility's care plans were not effectively implemented, as confirmed by the DON.
The facility did not meet the required RN-to-resident ratio on the overnight shift for eight out of 21 days reviewed. On several occasions, the facility had fewer RNs than required, with some nights having no RN present. This deficiency was confirmed by the Nursing Home Administrator and the DON.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
Richfield Healthcare and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the management of residents' personal funds. The facility failed to provide quarterly personal fund statements to two residents, as required by 42 CFR Part 483, Subpart B, and the 28 PA Code. Interviews with Resident 3 and her sister revealed that the sister was unaware of the handling of Resident 3's personal allowance, and neither had received a statement accounting for the funds. A review of Resident 3's financial records showed no withdrawals from the account, resulting in a balance of $1,772.28. Similarly, Resident 13 and her husband confirmed that they had not received quarterly statements for her personal funds, despite the facility automatically receiving her social security payments. The facility's business office manager admitted to not providing these statements, and the Nursing Home Administrator confirmed the lack of evidence for issuing such statements to Residents 3 and 13. This deficiency highlights the facility's failure to maintain a proper accounting system for residents' personal funds, as required by the regulations.
Plan Of Correction
1. Resident 3 and Resident 13, along with their responsible parties, were provided with their personal fund statements immediately upon identification of the issue. 2. The Business Office Manager (BOM) reviewed the personal fund accounts for all residents to ensure no other individuals were missing quarterly statements. Any identified residents were provided with their statements. The facility revised its Personal Funds Management Policy to include a mandatory process for documenting and distributing quarterly statements to residents. 3. The Business Office Manager (BOM) and NHA received re-education on regulatory requirements regarding personal fund statements, including the obligation to provide statements at least quarterly. This training was completed by Seasoned BOM at a sister facility on 2-10-2025. 4. The Business Office Manager or designee will conduct a monthly audit of 5 randomly selected residents' personal fund accounts to verify that statements have been provided at least quarterly. Audits will be reviewed in QAPI.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to adhere to food safety requirements as evidenced by improper food storage practices in the main kitchen. During an inspection, it was observed that a reach-in refrigerator contained items such as a carton of orange juice and portioned servings of applesauce and mixed fruit, all of which were past their use-by dates. Additionally, a one-gallon container of pickle relish was found without a use-by date, although it should have been discarded after one month according to the facility's guidelines. These observations were confirmed by Employee 3, the dietary manager, who acknowledged the discrepancies in food storage practices. Further inspection revealed that scooping utensils were improperly stored within food containers, specifically in bins containing sugar and a thickener, contrary to the facility's policy. The policy mandates that scoops should not be stored in contact with food products but should be kept in a protected area nearby. Employee 3 confirmed that the staff did not follow this policy. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to maintain professional standards for food service safety.
Plan Of Correction
1. Facility cannot retroactively correct. Expired and Improperly Labeled Food Items: - All expired food items (orange juice, applesauce, mixed fruit, and pickle relish) were immediately discarded. Improper Storage of Scooping Utensils: - Sugar and thickener bins were discarded and replaced with properly stored products. 2. Expired and Improperly Labeled Food Items: Kitchen staff re-educated on the facility's Food Storage Guidelines, including proper labeling with "use by" dates and discard dates for perishable items. Daily checks for expired food implemented, with findings logged and reviewed by the Dietary Manager. Improper Storage of Scooping Utensils: Dietary Staff re-trained on proper storage of scooping utensils, ensuring all utensils are stored outside food containers in designated, covered storage areas. 3. Dietary manager will educate dietary staff on: - Proper food storage and labeling policies. - Shelf life and expiration date tracking for all perishable and non-perishable items. - Proper handling and storage of food scoops and utensils. 4. Dietary manager and or designee will conduct Daily kitchen audits to verify compliance with food storage policies. The Dietary Manager and or designee will conduct weekly food inventory checks, ensuring: - All food items are properly labeled and stored. - No expired products remain in storage. Audits will be completed weekly for four weeks then monthly x 2 months. Results of audits will be reviewed in QAPI to determine ongoing monitoring.
Improper Handwashing Technique Observed During Medication Administration
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection on one of its nursing units. The deficiency was identified during a review of facility policies, observations, and staff interviews. The facility's handwashing policy, last reviewed without changes, requires staff to use a disposable towel to turn off the faucet as the last step of the handwashing technique. However, during a medication administration pass, an LPN was observed using the back of her arm to turn off the faucet after washing her hands, which is contrary to the facility's policy. The observations revealed that the LPN repeatedly used improper handwashing techniques while administering medications to multiple residents. For instance, after administering medications to a resident experiencing symptoms of a potential gastrointestinal infection, the LPN removed her personal protective equipment and washed her hands but used her arm to turn off the faucet. This improper technique was consistently observed during medication administration to several other residents, including those requiring blood glucose assessments and insulin injections. The LPN confirmed during an interview that she did not use a disposable towel to turn off the faucet after washing her hands. The surveyor discussed these handwashing concerns with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to adhere to its infection prevention and control program, specifically regarding hand hygiene procedures.
Plan Of Correction
1. Facility cannot retroactively correct. Employee 1 was immediately re-educated on proper handwashing technique, emphasizing the requirement to use a disposable towel to turn off faucets. 2. The Handwashing Policy was reviewed and reaffirmed with all staff. Copies of the policy and step-by-step handwashing guides are now posted at all handwashing stations. 3. Hand Hygiene Competency Checks and re-education on handwashing policy to be completed. All licensed nurses and CNAs will undergo a hand hygiene skills check-off by the Infection Preventionist or Director of Nursing (DON) and or designee to ensure compliance following the education on the facility's handwashing policy. 4. The DON, Infection Preventionist, or designee will conduct weekly random hand hygiene competencies for 4 weeks then monthly x 2 months. Audit findings will be documented and reviewed in monthly Quality Assurance & Performance Improvement (QAPI) meetings.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide the required written notification to a resident and their responsible party regarding a transfer to the hospital. For Resident 4, there was no documentation of written notification to the resident's responsible party about the transfer, which should have included the reason for the transfer, the effective date, the location, and a statement of the resident's right to appeal, among other required details. This deficiency was confirmed during an interview with a registered nurse supervisor. For Resident 13, the facility did not provide the resident's husband with the necessary written notice of the transfer to the hospital. Although a Notice of Transfer or Discharge was dated the day after the transfer, there was no evidence that the resident's husband received this notice, as the signature line for acknowledgment was blank. The resident's husband, who frequently visits the facility, could not recall receiving such a notice. The surveyor discussed these findings with the Nursing Home Administrator and the Director of Nursing, confirming the lack of compliance with the required notification process for both residents. The facility's failure to provide proper written notification for hospital transfers was identified as a deficiency in meeting the regulatory requirements for resident rights and notice requirements before transfer or discharge.
Plan Of Correction
1. The facility can not retroactively correct deficient practice. 2. The facility reviewed any resident transfers from the past 30 days to determine if any other residents or responsible parties were missing written notification of hospital transfers. Any identified deficiencies were immediately corrected. 3. NHA educated Social Services who received re-education on proper hospital transfer notification procedures, including: - The required elements of written notification. - Timely distribution and documentation of notifications. - The resident's right to appeal and required contact information for relevant agencies. - Ensuring responsible parties receive and acknowledge the notification. 4. The NHA and or designee will audit up to 5 random hospital transfers per month for three months to verify that: - Written notifications were completed. - All required elements were included. - Documentation was properly signed and acknowledged by the responsible party and if unable to get signature proof of mailed documentation was provided. Audit results will be reviewed by the QAPI team monthly to determine the need for ongoing monitoring.
Failure to Provide Bed-Hold Policy Notice Upon Resident Transfer
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy to a resident or the resident's responsible party upon transfer to a hospital. This deficiency was identified during a clinical record review and staff interview. Specifically, Resident 4 was transferred to the hospital from December 3 to 9, 2024, due to a change in condition. However, there was no documentation available indicating that the facility provided the required written notice regarding the bed-hold policy to the resident or the resident's responsible party at the time of transfer. An interview with Employee 4, a registered nurse supervisor, confirmed the absence of documentation for the bed-hold policy notice for Resident 4. This oversight was noted as a failure to meet the regulatory requirement outlined in §483.15(d)(1)(2), which mandates that nursing facilities provide written information about the bed-hold policy before and upon transfer of a resident.
Plan Of Correction
1. Facility can not retroactively correct. 2. The facility conducted a 30-day review of any hospital transfers to determine if any other residents were missing documentation of written bed-hold notifications. Any identified deficiencies were immediately corrected if able. 3. NHA educated Social Services whom received re-education on proper hospital transfer notification, which include: - The timing of the notice (must be provided at the time of transfer). - Documentation requirements to ensure the notice is placed in the resident's clinical record. - Resident and responsible party acknowledgment procedures. Licensed staff re-educated on the facilities Hospital Transfer Checklist which was re-implemented, requiring the nurse overseeing the transfer to confirm that the bed-hold notice was provided and documented on the Transfer out checklist. 4. The Director of Nursing (DON) or designee will audit 5 random hospital transfers per month for three months to verify that: - A written bed-hold notice was provided to the resident and/or responsible party. - Documentation was properly signed and checklist was filed in the clinical record. Audit results will be reviewed by the QAPI team monthly to determine the need for ongoing monitoring.
Inaccurate MDS Assessments for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident. The resident was readmitted from a hospital stay with a diagnosis of aspiration pneumonia and sepsis. However, subsequent MDS assessments inaccurately documented the resident as having pneumonia, septicemia, and a multidrug-resistant organism (MDRO) without any supporting evidence in the clinical record. These errors persisted across multiple assessments conducted on May 30, August 1, August 30, and November 27, 2024. An interview with the Administrator confirmed that these assessments were coded in error, as there was no documented evidence of the resident having these conditions since December 2023.
Plan Of Correction
1. The facility immediately corrected Resident 1's MDS and a modification of the MDS's was completed to reflect accurate diagnoses and care needs, removing coding that was selected for resident for having an active diagnosis of an infection which included one of the following: pneumonia, septicemia (a bloodstream infection), and a multidrug resistant organism (MDRO, an infection susceptible to certain antibiotics). There was no documented evidence in Resident 1's clinical record to indicate that she had a current pneumonia infection, septicemia, or an MDRO. MDS's were modified and diagnoses were updated to reflect current active diagnoses. 2. MDS staff member conducted a 30 day look back reviewing any residents who were coded for having a current pneumonia infection, septicemia, or an MDRO to ensure coding was accurate. - Active diagnoses were verified with progress notes, physician orders, and laboratory results with the MDS submission. - Any discrepancies will be addressed and modified/updated to reflect current care needs during the look back. 3. NHA to educate MDS staff providing re-education on: - Proper MDS coding practices, including reviewing physician orders and clinical documentation before finalizing assessments. - The importance of accurate coding to ensure appropriate care planning and reimbursement. 4. The MDS Coordinator or designee will audit 5 random selected MDS assessments per month for three months to verify if coding current pneumonia infection, septicemia, or an MDRO to ensure coding was accurate. Audit will include Active diagnoses accurately reflect the resident's current clinical condition during the MDS assessment look back. Audits will be reviewed in QAPI.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective interventions to prevent future falls for a resident identified as being at risk for falls due to decreased safety awareness. The resident was admitted on November 9, 2017, and a care plan was initiated on November 27, 2020, noting the risk for falls. Despite this, the resident experienced multiple falls, including an unwitnessed fall on October 10, 2024, where the resident was found on the floor with an abrasion above the ear. The facility's investigation into this incident did not result in any new interventions, and it was noted that the issue would be discussed at an interdisciplinary team meeting. Subsequent falls occurred on October 17, 2024, and December 20, 2024, with the resident being found on the floor on both occasions. Immediate actions taken included placing a pillow behind the resident's upper body and using blanket rolls on the sides of the mattress. However, these interventions were not documented in the resident's care plan. The only documentation of an interdisciplinary team meeting regarding the falls was dated January 8, 2025, after the resident had already experienced three falls. An interview with the Director of Nursing confirmed the lack of documentation and updates to the care plan to prevent further falls.
Plan Of Correction
1. Resident 5's care plan was updated to include the fall prevention interventions, which include: - Pillow placement behind upper body. - Blanket rolls on both sides of mattress. A full review of Resident 5's fall history was completed by IDT to ensure all interventions are appropriate and accurate to meet the residents needs per plan of care as well to ensure they are in place. 2. DON/IDT will complete a look back of the past 30 days of residents who had a fall. Falls will be reviewed to ensure interventions are documented in their care plan and are in place to meet the needs of the residents plan of care. Weekly IDT fall meetings will be started to review the falls during that week to ensure appropriate interventions are put in place and documented in their care plan. 3. DON/designee will provide re-education for Nursing and IDT Staff on timely documentation of fall prevention interventions in residents' care plans as well as implementation of weekly fall meetings on reviewing residents who fell and ensuring interventions are appropriate and effective to meet the needs of the resident. 4. The DON or designee will audit 5 random resident fall cases per month for three months to ensure: - Fall prevention interventions are documented in care plans post fall. - IDT meetings are held within a minimum of 72 hours of each fall. - Weekly IDT Fall meetings are held to discuss residents who fall and to ensure interventions are in place and documented in care plan and meet the plan of care needs. Audit results will be reviewed monthly by the QAPI team to assess trends and determine if ongoing monitoring is necessary.
Failure to Conduct and Document Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the drug regimen of a resident was reviewed by a consultant pharmacist as required. Specifically, the consultant pharmacist reports from July and October 2024 did not include Resident 13, indicating that her medication regimen was not reviewed during these months. This oversight was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the absence of a report for Resident 13 for the specified months. Additionally, there was no documentation in Resident 13's clinical record to indicate that any irregularities were identified or reported to her attending physician. Consequently, there was no evidence that the attending physician reviewed any potential irregularities or documented any actions taken in response. This lack of documentation and communication represents a failure to comply with the regulatory requirements for drug regimen review and reporting.
Plan Of Correction
1. The facility cannot retroactively correct deficient practice. 2. The DON/designee will do a 30 day look back to ensure pharmacy consultant reviews requiring recommendations are reviewed by MD and are followed up on. The facility's Medical Records Coordinator or designee will maintain a log of pharmacist reports, ensuring all residents are listed in each month's review. The attending physician receives and reviews all recommendations. Documentation of physician action is entered into the resident's chart. 3. The NHA will educate Director of Nursing (DON) on: - Verifying that all consultant pharmacist recommendations are received, reviewed, and acted upon by the physician. - Ensuring documentation of physician response is entered into the medical record. 4. The DON or designee will audit monthly pharmacy reviews to ensure recommendations are followed up and completed by a physician and are then placed in the resident records each month. The QAPI team will review pharmacy audits monthly to assess ongoing monitoring.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate based on 25 medication opportunities with two errors. One error involved the administration of insulin to a resident using a Fiasp FlexTouch pen. The LPN did not follow the manufacturer's instructions for priming the pen, which required two units of insulin to be used for priming. Instead, the LPN primed the pen with only one unit before administering the prescribed two units to the resident, who had a blood glucose level of 199 mg/dL. Another error occurred during the administration of Polyethylene Glycol to a different resident. The LPN used a plastic medication cup to measure the dose instead of the cap provided with the medication container, which is designed to measure the correct 17 grams dose. This resulted in the resident receiving an incorrect amount of the medication. The LPN confirmed the errors during an interview, acknowledging the lack of access to the manufacturer's instructions for the insulin pen and the incorrect measurement method for the Polyethylene Glycol.
Plan Of Correction
1. Facility can not retroactively correct deficient practice. Resident 2: - The physician was notified of the insulin administration error, and no adverse effects were noted. - The insulin pen administration policy was reviewed, and staff were re-educated on proper priming procedures. Resident 14: - The physician was notified of the Polyethylene Glycol administration error, and no adverse effects were noted. 2. Facility will review and update their Policy and Procedures specifically: - The facility's "Administering Medications" and "Insulin Administration" policies were updated to: - Include detailed priming instructions for all insulin pens based on manufacturer guidelines. - Emphasize measuring medications using manufacturer-provided tools. - The medication administration policy was reviewed, and staff were re-educated on measuring medications according to manufacturer instructions. 3. All licensed nurses will be educated on updated policies and ensuring to follow manufacturer guidelines and will complete competency assessments on: - Insulin administration using prefilled pens and priming. - Proper measurement of powdered medications based on manufacturer guidelines. 4. The Director of Nursing (DON) or designee will conduct random medication pass audits on five nurses per week for four weeks to ensure: - Proper priming of insulin pens. - Correct medication measurement techniques on powdered medications. Audits will be conducted monthly for two months and Medication pass audit results will be reviewed in monthly QAPI meetings to ensure continued compliance and determining ongoing auditing.
Medication Labeling Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that medication was labeled in accordance with accepted professional standards for a resident. The facility's policy on administering medications, last reviewed without changes on December 31, 2024, requires that medications be administered according to prescriber orders, with the individual administering the medication checking the label three times to verify the right resident, medication, dosage, time, and method of administration. However, during a medication administration pass, it was observed that an LPN prepared Clonazepam 0.5 mg for a resident, pouring two tablets for administration, despite the label instructing staff to administer one tablet by mouth twice daily and two tablets at bedtime. The discrepancy between the label instructions and the active physician's order, which required one tablet by mouth two times a day and two tablets in the afternoon, was confirmed by the LPN. The label indicated that the pharmacy filled 30 tablets on January 24, 2025, and there were 23 tablets available at the time of observation, suggesting that seven tablets had been administered before the LPN removed two additional tablets. The concerns regarding medication labeling were discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Resident 14: The physician was immediately notified of the medication label discrepancy. No medication error occurred as the labeled only had discrepancy; nurses followed order in EHR system. The pharmacy was contacted, and a corrected label was issued to match the active physician's order. 2. A full house medication cart audit will be completed to ensure labels are cross-checked against physician orders. If discrepancies are identified, the pharmacy and physician will be notified immediately for resolution. If it is the same medication dosage but a change in time, a change in direction label will be placed on medication until new medication with updated labeling matching the order is received from the pharmacy. 3. The DON will provide re-education to licensed nursing staff on proper medication verification procedures, emphasizing the importance of ensuring that: - The medication label matches the active physician's order. - Any discrepancies are immediately reported to the pharmacy and physician before administration. 4. The Director of Nursing (DON) or designee will conduct random weekly audits of medication labels vs. physician orders for four weeks to ensure compliance, then monthly for 2 months. Medication label audit results will be reviewed in monthly QAPI to determine ongoing monitoring.
Failure to Provide Routine Dental Care for Residents
Penalty
Summary
The facility failed to assist two residents in obtaining routine dental care, as required by regulations. Resident 4, who was admitted in February 2024, had several broken and missing teeth, but there was no documentation of routine prophylactic dental cleanings since admission. Despite a comprehensive dental assessment in October 2024, the facility did not provide evidence of any follow-up cleanings. Nursing documentation noted Resident 4's broken tooth in January 2025, but the facility did not act promptly to address his dental needs. Resident 3 had discolored, possibly broken, and missing teeth, and expressed the need for a tooth extraction. A dental note from July 2024 recommended the extraction of two non-restorable teeth, but there was no evidence of routine dental services being provided every six months as covered under the State plan. The facility's care plan for Resident 3, initiated in March 2020, included annual and as-needed dental referrals, but the facility failed to ensure these services were provided, as confirmed by the Director of Nursing.
Plan Of Correction
1. Resident 4: - The dentist was contacted for an evaluation of Resident 4's dental needs. The resident's dental care plan was updated to ensure routine six-month dental cleanings and ongoing monitoring for additional care needs. Resident 3: - A dental appointment was scheduled to reassess the condition of Resident 3's teeth and determine the need for extractions. Resident 3 was placed on a recurring schedule for prophylactic cleanings every six months, per State Plan coverage. 2. The Social Services Director (or designee) will conduct monthly audits to ensure all residents are receiving routine dental services and timely interventions for identified dental needs. The Facility will implement a designated staff member who will have and maintain a standardized process for tracking and following up on dentist recommendations with a Dental Services Log to track all resident dental visits, cleanings, and follow-ups. 3. The NHA will provide education to the DON and social service staff as well as a designated designee assigned to this with re-educated on routine and as-needed dental care, including: - Proper documentation of dental services provided. - Scheduling requirements for semi-annual cleanings and dentist referrals for issues such as broken teeth or cavities. - Timely follow-up on dentist recommendations and care plan updates. - Calendar record maintained for compliance tracking. 4. The DON or designee will conduct random chart audits weekly for four weeks to ensure all residents are receiving appropriate dental services and care. Audit results will be reviewed in QAPI meetings to determine ongoing monitoring.
Failure to Meet RN Staffing Requirements on Overnight Shifts
Penalty
Summary
The facility failed to comply with the regulation requiring a minimum of one registered nurse (RN) per 250 residents during all shifts. This deficiency was identified during a review of nursing staffing hours and staff interviews, which revealed that the facility did not meet the required RN-to-resident ratio on the overnight shift for eight out of the 21 days reviewed. Specifically, on several dates between November 2024 and February 2025, the facility had fewer RNs than required, with some nights having no RN present at all. The Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to meet the regulatory RN-to-resident ratios during an interview on February 6, 2025.
Plan Of Correction
1. Facility can not retroactively correct. 2. Facility can not retroactively correct. Facility will continue to recruit and retain RN staff through a variety of services. 3. NHA/Designee will educate the scheduler and DON on state regulation. DON or designee will conduct review of staffing deployment assignments daily to ensure the staffing ratio is being met for a period of 4 weeks and a weekly review x 2 months. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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