Pennsylvania Department of Health
RIVERSTREET MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIVERSTREET MANOR
Inspection Results For:

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

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


RIVERSTREET MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Revisit Survey completed on July 14, 2026, it was determined that Riverstreet Manor corrected the federal deficiencies cited during the surveys of April 17, 2026, May 28, 2026 and June 24, 2026 , under the of 42 Part 483 Subpart B Requirements for Long Term Care Facilities however remained out of compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 7 shifts out of 21 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, and 1:11 on the evening shift, based on the facility's census:

July 7, 2026, 9.50 NAs on the day shift, versus the required 10.20, for a census of 102.
July 7, 2026, 8.00 NAs on the evening shift, versus the required 9.27, for a census of 102.
July 8, 2026, 10.00 NAs on the day shift, versus the required 10.20, for a census of 102.
July 8, 2026, 8.00 NAs on the evening shift, versus the required 9.27, for a census of 102.
July 9, 2026, 9.50 NAs on the day shift, versus the required 10.30, for a census of 103.
July 9, 2026, 9.00 NAs on the evening shift, versus the required 9.36, for a census of 103.
July 10, 2026, 10.00 NAs on the day shift, versus the required 10.40, for a census of 104.

On the above dates mentioned no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Nursing Home Administrator, on July 14, 2026, at 1:30 PM, confirmed the facility had not met the required NA to resident ratios on the above dates.

Plan of Correction - To be completed: 08/11/2026

1. The facility will provide a minimum nurse aide staff of 1:10 on day shift, and 1:11 on evening shift to ensure minimum staffing levels are met.
2. The Director of Nursing, Administrator, and Scheduling Manager will review staffing schedules daily, including upcoming weekend to ensure staffing ratio and minimum staff requirements are met. Any identified staffing deficiency will be immediately addressed utilizing overtime, agency personnel, internal float staff, shift incentives, management coverage, and assistance from corporate leadership.
3. The facility's staffing tool will be reviewed daily based on census and resident acuity to ensure appropriate staffing levels are scheduled. The Administrator and Director of Nursing will approve all schedules prior to posting and will conduct daily staffing huddles Monday through Friday to review vacancies, recruitment activities, anticipated call-off's, agency utilization, and contingency plans. Human Resource Director will hold weekly meetings with recruitment company to fill identified needs.
4. The Administrator/designee will complete weekly audits for four weeks, then monthly for two months to ensure minimum staffing standards are met. The results of these audits will be reviewed in monthly quality assurance meeting.
5. The Administrator/designee will complete weekly audits times four weeks, then monthly times two months to ensure minimum staffing standards are met.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 08/11/2026

1. The facility will provide a minimum licensed practical nurse staff of 1:25 on day shift, 1:30 on the evening shift and 1:40 on the night shift to ensure minimum staffing levels are met.
2. The Director of Nursing, Administrator, and Scheduling Manager will review staffing schedules daily, including upcoming weekend to ensure staffing ratio and minimum staff requirements are met. Any identified staffing deficiency will be immediately addressed utilizing overtime, agency personnel, internal float staff, shift incentives, management coverage, and assistance from corporate leadership.
3. The facility's staffing tool will be reviewed daily based on census and resident acuity to ensure appropriate staffing levels are scheduled. The Administrator and Director of Nursing will approve all schedules prior to posting and will conduct daily staffing huddles Monday through Friday to review vacancies, recruitment activities, anticipated call-off's, agency utilization, and contingency plans. Human Resource Director will hold weekly meetings with recruitment company to fill identified needs. LPN wage analysis completed.
4. The Administrator/designee will complete weekly audits for four weeks, then monthly for two months to ensure minimum staffing standards are met. The results of these audits will be reviewed in monthly quality assurance meeting.
5. The Administrator/designee will complete weekly audits times four weeks, then monthly times two months to ensure minimum staffing standards are met.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily on 1 out of 21 days reviewed.

Findings include:

A review of the facility's staffing levels revealed that on the following date the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:

July 7, 2026 3.10 direct care nursing hours per resident.

The facility's general nursing hours were below the minimum required levels on the date noted above.

An interview was conducted with the Director of Nursing on July 14, at 1:45 PM to review the above findings related to the facility's failure to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 08/11/2026

1. The facility will provide minimum nurse staffing of 3.2 hours of general nursing care to each resident.
2. The Director of Nursing, Administrator, and Scheduling Manager will review staffing schedules daily, including upcoming weekend to ensure staffing ratio and minimum staff requirements are met. Any identified staffing deficiency will be immediately addressed utilizing overtime, agency personnel, internal float staff, shift incentives, management coverage, and assistance from corporate leadership.
3. The facility's staffing tool will be reviewed daily based on census and resident acuity to ensure appropriate staffing levels are scheduled. The Administrator and Director of Nursing will approve all schedules prior to posting and will conduct daily staffing huddles Monday through Friday to review vacancies, recruitment activities, anticipated call-off's, agency utilization, and contingency plans. Human Resource Director will hold weekly meetings with recruitment company to fill identified needs.
4. The Administrator/designee will complete weekly audits for four weeks, then monthly for two months to ensure minimum staffing standards are met. The results of these audits will be reviewed in monthly quality assurance meeting.
5. The Administrator/designee will complete weekly audits times four weeks, then monthly times two months to ensure minimum staffing standards are met.

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