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
- 19
- 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
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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