Pennsylvania Department of Health
RICHBORO REHABILITATION & NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RICHBORO REHABILITATION & NURSING CENTER
Inspection Results For:

There are 142 surveys for this facility. Please select a date to view the survey results.

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RICHBORO REHABILITATION & NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on May 29, 2025, it was determined that Richboro Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian.

Findings include:

During an interview on May 28, 2025, at 10:45 a.m., the dietary manager stated the facility did not employ a qualified dietary manager. There was no evidence that the facility had a qualified dietary services manager or a full-time dietitian. In an interview conducted on May 29, 2025, at 11:00 a.m., the Administrator confirmed that there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian.

28 Pa. Code 201.18(b)(3) Management.

Plan of Correction - To be completed: 07/08/2025

1. The facility will hire a certified dietary manager, or certified food service manager with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for food service management.

2. The facility has reviewed the current dietary staffing to ensure steps are taken to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service management to meet requirements of F801

3. Education will be provided to NHA by RDO/designee to assure facility employs sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service management to meet requirements of F801.

4. The facility will conduct bi-weekly review x 2 then monthly review x 1 of dietary staffing to ensure that facility has sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service management to meet requirements of F801. Results of audits will be reviewed by the QAPI committee monthly.

5. Date of Compliance: 7/8/25

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 19 sampled residents. (Resident 34 and 54)

Findings include:

Review of the policy entitled, "Medication Administration," last reviewed January 30, 2025, revealed staff was to obtain and record vital signs in the Medication Administration Record (MAR) per physician order, and when applicable, hold medication for those vital signs outside of the physician's prescribed parameters.

Clinical record revealed that Resident 34 had diagnoses that included hypertension (high blood pressure). On February 28, 2025, a physician ordered staff to administer a blood pressure medication (metoprolol succinate) two times a day. Staff was to not to administer the medication if the resident's heart rate was less than 60 beats per minute (BPM). Review of Resident 34's MARs revealed that staff administered the medication 30 times in April 2025, and 27 times in May 2025, with no documentation that the resident's heart rate was assessed prior to the medication administration.

In an interview on May 29, 2025, at 10:00 a.m., the Assistant Director of Nursing confirmed there was no documented evidence to support that the heart rate was taken prior to the medication administration for Resident 34 and it should have been in the MAR.

Clinical record review revealed that Resident 54 had diagnoses that included hypertension and diabetes. On October 9, 2024, the physician ordered staff to administer a blood pressure medicine (metoprolol tartrate) twice a day. Staff was not to administer the medication if the heart rate was less than 60 BPM. Review of Resident 54's MARs revealed that staff administered the medication two times in April 2025, and two times in May 2025, when the resident's heart rate was below 60 BPM.

In an interview on May 29, 2025, at 9:50 a.m., the Director of Nursing confirmed that the medication was administered outside of the established parameters for Resident 54.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 07/08/2025

1. The facility cannot retroactively correct the issue. R34 and R54 had no adverse effects.

2. Current residents on antihypertensives with physician ordered parameters will be reviewed to ensure that medications are administered as ordered. Any issues identified will be addressed with the physician.

3. Licensed nurses will be educated on the importance of following physician ordered parameters for antihypertensives.

4. DON/designee will review EMAR of residents with physician ordered parameters to ensure that physician orders are being followed. Audits will be completed daily for three days then weekly for 3 weeks, then monthly x 2 or until 100% compliance is achieved. Any identified issues will be addressed with the physician. Results of audits will be reviewed by the QAPI committee monthly

5. Date of Compliance 7/8/25

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:

Based on review of facility documentation, the facility's meal schedule, resident and staff interview, and observation, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs for one of five meal carts. (Doc's dining room)

Findings include:

Review of the Food Committee Minutes from March 26, 2025, and April 30, 2025, revealed that residents had stated that their meal trays were often served late. In a group interview on May 28, 2025, at 10:30 a.m., Residents 3, 9, 24, 34, 58, and 60, stated that the meals were frequently delivered late to the main dining room and it was an on-going problem. In an interview on May 28, 2025 at 12:15 p.m., Resident 35 stated that meal trays can often be served late.

Review of the facility's meal schedule revealed that the scheduled time for lunch in Doc's dining room was 12:30 p.m.

Observation on May 28, 2025, in the Doc's dining room, revealed the meal cart arrived at 12:50 p.m., 20 minutes after the scheduled delivery time. On May 29, 2025, the Doc's dining room cart arrived at 12:53 p.m., 23 minutes after the scheduled delivery time.

In an interview on May 29, 2025, at 10:00 a.m., the Administrator confirmed the Doc's dining room meal service was late on the previously mentioned days.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 07/08/2025

1. The facility cannot retroactively correct the issue.

2. The food service director/designee has reviewed the meal delivery schedule on 5/30/24 to ensure that meals are served at regularly scheduled times in accordance with resident needs.

3. The dietary staff will be educated by NHA/designee that meals should be served at regularly scheduled times to meet resident needs.

4. The food service director/designee will conduct observational audits to ensure that meals are served at regularly scheduled times to meet resident needs. The audits will be completed daily for three days then weekly for 3 weeks, monthly x 2 or until 100% compliance is achieved. Results of audits will be reviewed by the QAPI committee monthly.

5. Date of Compliance 7/8/25

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