Pennsylvania Department of Health
RICHLAND NURSING AND REHAB
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RICHLAND NURSING AND REHAB
Inspection Results For:

There are 135 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.


RICHLAND NURSING AND REHAB - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey, completed on January 30, 2026, it was determined that Richland Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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.

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure thatthe resident's care plan reflected the resident's specific care needs for two of 35 residents (Resident 2 and Resident 61).

Findings Include:

A facility policy for comprehensive care plans, dated November 26, 2025, indicated that it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will describe individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 12, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and PTSD.

There was no documented evidence that Resident 2's care plan reflected the diagnosis of PTSD with associated triggers.

Interview with the Social Worker on January 30, 2026, at 09:18 a.m. revealed that the facility was not completing trauma informed care assessments and that they should be. In addition, the facility did not assess or identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 2.

Interview with the Director of Nursing on January 30, 2026, at 10:18 a.m. confirmed that Resident 2's care plan should have been updated to reflect the diagnosis of PTSD and potential triggers to avoid.

A quarterly MDS assessment for Resident 61, dated November 14, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, received antidepressant medications (a psychotropic medication used to treat depression) and had diagnoses that included anxiety and depression. Psychotropic medications are medications used to treat mental health disorders by altering brain chemistry.

A physician's order for Resident 61, dated December 31, 2025, included an order for the resident to receive 5 milligrams (mg) of Olanzapine (a psychotropic medication classified as an antipsychotic medication used to treat mental health disorders) daily at bedtime related to major depression.

There was no documented evidence in Resident 61's medical record that a comprehensive care plan was developed to reflect the resident's need for an antipsychotic medication.

Interview with the Director of Nursing on January 29, 2026, at 5:45 p.m. confirmed that there was no documented evidence in Resident 61's medical record that a comprehensive care plan was developed to reflect the resident's need for an antipsychotic medication.

28 Pa. Code 211.11(d) Resident care plan

Plan of Correction - To be completed: 03/03/2026

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Residents 61's care plan was updated to reflect current use of anti-psychotic medications. Trauma assessment completed on resident 2 and no triggers were identified.

2. Residents with anti-psychotic medications and Post Traumatic Stress Disorder (PTSD) diagnosis were reviewed to ensure care plans were accurate. Residents with PTSD were reviewed to ensure trauma informed assessment was completed. Social Services Director was educated by Director of Nursing on trauma informed care and the integration of specific medical and psychological needs into care plans.

3. Registered Nurse Assessment Coordinator (RNAC), or designee, to complete audit on three residents with anti-psychotic medications or trauma diagnosis to ensure accurate care plan is in place weekly times four weeks and monthly times two months.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

483.25 REQUIREMENT Quality of Care:

§ 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 clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 35 residents reviewed (Resident 80).

Findings include:

A facility policy for Medication Administration, dated November 26, 2025, indicated that medications will me administered as per the the physicians orders.

A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 80, dated January 17, 2026, revealed that the resident was moderately cognitively impaired, had clear speech, understood and understands and had diagnoses that included heart disease and high blood pressure, and on May 13, 2025, was originally ordered 5 milligrams (mg) Lisinopril (a medication to treat high blood pressure) one time a day.

A nursing note for Resident 80, dated October 8, 2025, at 12:07 p.m. indicated that the resident had an episode of dizziness and a blood pressure of 92/60 millimeters of mercury (mm/Hg).

Physician's orders for Resident 80, dated October 9, 2025, included an order for the resident to receive 2.5 (mg) of Lisinopril one time a day, from October 9, 2025 to January 28, 2026, with the following blood pressure perimeters; hold if systolic (top number, when blood pushes out the heart) is less than or equal to 120 mm/Hg.

A review of Resident 80's Medication Administration Record (MAR) for October 2025 through January 2026 revealed that on the following dates the resident received her lisinopril despite the blood pressure being too low to administer; October 23, 2025, 116/78 mm/Hg; November 2, 2025, 116/74 mm/Hg ; November 7, 112/70 mm/Hg; and November 20, 118/76 mm/Hg; December 28, 116/70 mm/Hg; January 1, 2026, 108/68 mm/Hg ; January 5, 108/66 mm/Hg; January 10, 114/76 mm/Hg; January 17, 110/60 mm/Hg; January 19, 112/66 mm/Hg; January 20, 120/88 mm/Hg; January 21, 112/62 mm/Hg; and January 28, 116/58 mm/Hg.

On the following dates the resident did not receive the lisinopril despite the blood pressure being within the appropriate range to receive it, November 20, 2025, 124/70 mm/Hg and January 16, 2026, 142/88 mm/Hg

Interview with the Assistant Director of Nursing on January 29, 2026, at 11:20 a.m. confirmed that Resident 80's Lisinopril was not held or administered on the above dates and times as ordered by the physician.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 03/03/2026

1. Resident 80 had no ill effects from failure to follow physician order and medication was discontinued on 01/28/2026 after blood pressures were reviewed by Certified Registered Nurse Practitioner (CRNP).

2. Residents with blood pressure medications with hold parameters were reviewed and no additional errors were identified. Licensed nursing staff educated by the Director of Nursing on the importance of adhering to physician orders, specifically focusing on blood pressure parameters for withholding medications.

3. Director of Nursing, or designee, will audit three residents with blood pressure medications with hold parameters weekly times four weeks and monthly times two months to ensure physician order is being followed.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received proper care for an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine) for one of 35 residents reviewed (Resident 94).

Findings include:

The facility's policy regarding urinary catheter care, dated November 26, 2025, indicated that the purpose of this policy was to prevent catheter-associated urinary tract infections. General guidelines related to infection control indicated to make sure the catheter tubing and drainage bag were kept off the floor.

An admission note for Resident 94, dated January 27, 2026, indicated that the resident was admitted to the facility for a three-day respite stay. A care plan for the resident, dated January 28, 2026, indicated that the resident had an indwelling urinary catheter related to urinary retention.

Physician's orders for Resident 94, dated January 28, 2026, included an order for the resident to have an indwelling urinary catheter due to urinary retention.

Observations on January 28, 2026, at 1:06 p.m. revealed that Resident 94 was lying in a low bed with his catheter bag hanging on the left side of his bed in a privacy bag with the catheter tubing lying in direct contact with the floor.

Interview with Nurse Aide 1, on January 28, 2026, at 1:09 p.m. confirmed that Resident 94's catheter tubing was lying in direct contact with the floor and it should not have been.

Interview with the Director of Nursing on January 28, 2026, at 5:36 p.m. confirmed that Resident 94's catheter tubing should not have been in direct contact with the floor. She indicated that they used to have hooks/clips to help keep the tubing off the floor.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Plan of Correction - To be completed: 03/03/2026

1. Resident 94's foley catheter was removed from the floor and properly secured to prevent contact with the floor.

2. Residents with foley catheters were checked to ensure the tubing was secure and not on the floor. No concerns were identified. Nursing staff educated by the Assistant Director of Nursing on the importance of securement of catheter tubing and drainage bags, focusing on infection control measures and urinary tract infection (UTI) prevention.

3. Assistant Director of Nursing, or designee, will audit three residents weekly times four weeks and monthly times two months to ensure catheter tubing is secure and off the floor.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 35 residents reviewed (Resident 2).

Findings include:

Trauma informed care policy dated November 26, 2025, revealed that the facility will deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 12, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and PTSD. A review of Resident 2's care plan, dated September 29, 2025, indicated that the resident had PTSD and dementia.

There was no documented evidence the facility identified Resident 2's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.

Interview with the Social Worker on January 30, 2026, at 09:18 a.m. revealed that the facility was not completing trauma informed care assessments and that they should be. In addition, the facility did not assess or identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 2.

28 Pa Code 211.12(a)(d)(3)(5) Nursing services.

28 Pa Code 211.11(d) Resident care plan.

28 Pa. Code 211.16(a) Social services.

Plan of Correction - To be completed: 03/03/2026

1. Trauma assessment completed on resident 2 and no triggers were identified.

2. There were no other residents identified to have trauma or Post Traumatic Stress Disorder (PTSD) diagnosis at time of review. Social Services Director was educated by the Director of Nursing on the completion of the trauma informed care assessment on residents diagnosed with PTSD and identifying triggers.

3. Registered Nurse Assessment Coordinator, or designee, will audit for completion of trauma informed care assessments and identifying triggers that could re-traumatize residents with past traumas weekly times four weeks and monthly times two months.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policies and medication package inserts, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of medications with the date they were opened in one of two medication carts reviewed (C hall cart).

Findings include:

The facility's policies regarding medication storage and disposal, dated November 26, 2025, revealed that the facility would properly date medication vials after they were opened. An undated package insert for Degludec (a diabetic medication) revealed that it should be used within 56 days upon opening. An undated package insert for NovoLog (a diabetic medication) revealed that the medication should be used within 28 days of opening. An undated package inserts for Humalog Kwikpen (a diabetic medication) revealed that it should be used after 28 days of opening.

Observations in the C Hall cart on January 28, 2026, at 9:54 a.m. revealed that there was an 100 unit/ml Humalog Kwik Pen for Resident 31 open and undated, a 100 unit/ml Novolog Flex Pen and a 100 unit/ml Degludec FlexTouch pen for Resident 94 open, undated, and did not have a cap.

Interview with Licensed Practical Nurse 3 on January 28, 2026, at 10:08 a.m. confirmed that the medication should have been dated upon opening.

Interview with the Director of Nursing on January 28, 2026, at 4:15 p.m. confirmed that the medications should have been dated upon opening, and it should have had a cap.

28 Pa. Code 211.9(a)(1) Pharmacy services.

Plan of Correction - To be completed: 03/03/2026

1. Multi-dose vials of medications that were opened and undated for residents 31 and 94 were discarded and replaced with new medications that were properly dated.

2. Medication carts were audited for undated insulin pens and no other concerns were identified. Licensed nursing staff were educated by the Director of Nursing on the proper dating and storage of multi-dose vials.

3. Registered Nurse Assessment Coordinator (RNAC) will conduct audits of medications carts for opened insulin pens to ensure they are properly dated and capped weekly times four weeks and monthly times two months.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils:

§483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Observations:

Based on review of facility policies, and clinical records, as well as observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to assist with eating in accordance with physician's orders for one of 35 residents reviewed (Resident 63).

Findings include:

The facility's policy regarding assistive devices and equipment, dated November 26, 2025, revealed that
certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include specialized eating utensils and equipment. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated November 25, 2025, revealed that the resident was cognitively impaired, required set-up assistance with eating, had limited range of motion to his upper extremity on one side, and had a diagnosis of monoplegia (paralysis affecting one limb) following a cerebral vascular accident (stroke) affecting his left side. A nutrition care plan for Resident 63, dated June 21, 2025, indicated that the resident was to have adaptive equipment as ordered.

Physician's orders for Resident 63, dated January 5, 2026, included an order for the resident to have an inner lip plate (plate that reduces food spillage) for meals.

A nutrition note for Resident 63, dated January 13, 2026, at 9:44 a.m. indicated that the resident utilizes an inner lip plate for adaptive equipment.

Observations of Resident 63 during the breakfast meal on January 30, 2026, at 8:38 a.m. revealed that the resident was sitting up in bed eating his breakfast meal served on a regular plate. The resident was having difficulty getting the food onto his fork and he had a large amount of food resting on his chest. The resident's meal ticket on his tray at that time indicated that the resident was to have an inner lip plate for meals.

An interview with LPN 2 on January 30, 2026, at 8:40 a.m. confirmed that Resident 63 did not have an inner lip plate for breakfast and should have per his meal ticket. She stated she would address it with dietary.

An interview with the Director of Nursing on January 30, 2026, at 8:42 a.m. confirmed that Resident 63 should have had an inner lip plate as ordered.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Plan of Correction - To be completed: 03/03/2026

1. Resident 63 was given proper adaptive equipment upon recognition.

2. Residents ordered adaptive equipment were audited to ensure proper equipment was in place, no concerns were identified. Dietary staff were educated by the Registered Dietician on the proper placement of adaptative equipment and the importance of use.

3. Dietary Manager, or designee, will audit for the proper administration of adaptive equipment with meals for three residents weekly times four weeks and monthly times two months.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety.

Findings include:

Observations of the walk-in cooler on January 28, 2026, at 9:42 a.m. revealed one quarter bushel of moldy cucumbers. Observations of the walk-in freezer on January 28, 2026, at 9:40 a.m. revealed that there was half of a box of Tony's pizzas, half of a bag of chicken tenders, one box of breadsticks that were opened, undated and exposed to the air. Observations of the small refrigerator in the kitchen on January 28, 2026, at 9:47 a.m. revealed half of a container of heavy whipping cream that was opened and undated. Observations of the residents' refrigerator on January 28, 2026, at 9:53 a.m. revealed half of a container of soup that was undated, with a brown and white removable substance around the lid.

Interview with the Dietary Director on January 28, 2026, at 9:53 a.m. confirmed that food should be dated when it is opened and should be properly sealed for storage, and that resident food should be thrown out when it shows signs of spoilage.

28 Pa. Code 211.6(f) Dietary Services.

28 Pa. Code 207.4 Ice Containers and Storage.

Plan of Correction - To be completed: 03/03/2026

1. Spoiled and undated opened food was discarded.

2. Fridge, freezer and pantry were checked to ensure no other undated, opened, or spoiled food was present- no further concerns were identified. Dietary staff educated by the Registered Dietician regarding the proper storage and labeling of opened food, and disposal of food showing signs of spoilage.

3. Dietary manager, or designee, will audit for properly sealed and dated food after opening and disposal of food showing signs of spoilage.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

§ 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 review of nursing schedules, staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide one nurse aide (NA) per 10 residents on the day shift for one of 21 days, and failed to provide one NA per 15 residents on the night shift for two of 21 days reviewed for December 20 through December 26, 2025; December 31, 2025 through January 6, 2026; and January 23 through January 29, 2026.

Findings include:

Review of facility census data revealed:

On January 1, 2026, the facility census was 80, during the day shift, which required 8.00 NA's during the day shift. Review of the nursing time schedules revealed 7.27 NA's provided care on the day shift.

On December 31, 2025, the facility census was 80, during the night shift, which required 5.33 NA's during the night shift. Review of the nursing time schedules revealed 4.67 NA's provided care on the night shift.

On January 24, 2026, the facility census was 92, during the night shift, which required 6.13 NA's during the night shift. Review of the nursing time schedules revealed 4.17 NA's provided care on the night shift.

However, there were no additional excess higher-level staff available to compensate for these deficiencies.

Interview with the Nursing Home Administrator on January 30, 2026, at 1:30 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.

Plan of Correction - To be completed: 03/03/2026

1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met.

2. The facility will continue to take measures to adequately provide staff to meet the required Certified Nursing Assistants (CNA) to resident ratios. When total CNA to resident ratios are unable to be met, and no higher properly licensed staff are able to supplement those hours, the facility will reevaluate the acceptance of new admissions. The Nursing Home Administrator, or designee ,will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing ratios.

3. The Nursing Home Administrator, or designee, will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

§ 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.

Observations:

Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents on the day shift for one of 21 days reviewed and failed to provide a minimum of one LPN per 40 residents on the night shift for six of 21 days reviewed for December 20 through December 26, 2025; December 31, 2025 through January 6, 2026; and January 23 through January 29, 2026.

Findings include:

Review of facility census data revealed:

On January 1, 2026, the facility's census was 80 during the day shift, which required 3.20 LPN's on the day shift. Review of the nursing time schedules revealed that 3.06 LPN's provided care during the day shift.

On January 23, 2026, the facility's census was 92 during the night shift, which required 2.30 LPN's on the night shift. Review of the nursing time schedules revealed that 2.16 LPN's provided care during the night shift.

On January 24, 2026, the facility's census was 92 during the night shift, which required 2.30 LPN's on the night shift. Review of the nursing time schedules revealed that 2.25 LPN's provided care during the night shift.

On January 25, 2026, the facility's census was 91 during the night shift, which required 2.28 LPN's on the night shift. Review of the nursing time schedules revealed that 2.19 LPN's provided care during the night shift.

On January 26, 2026, the facility's census was 90 during the night shift, which required 2.25 LPN's on the night shift. Review of the nursing time schedules revealed that 2.22 LPN's provided care during the night shift.

On January 27, 2026, the facility's census was 89 during the night shift, which required 2.23 LPN's on the night shift. Review of the nursing time schedules revealed that 2.22 LPN's provided care during the night shift.

On January 28, 2026, the facility's census was 89 during the night shift, which required 2.23 LPN's on the night shift. Review of the nursing time schedules revealed that 2.19 LPN's provided care during the night shift.

However, there were no additional excess higher-level staff available to compensate for these deficiencies.

Interview with the Nursing Home Administrator on January 30, 2026, at 1:30 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.

Plan of Correction - To be completed: 03/03/2026

1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met.

2. The facility will continue to take measures to adequately provide staff to meet the required Licensed Practical Nurse (LPN) to resident ratios. When total LPN to resident ratios are unable to be met, and no higher properly licensed staff are able to supplement those hours, the facility will reevaluate the acceptance of new admissions. The Nursing Home Administrator, or designee, will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing and staffing ratios.

3. The Nursing Home Administrator, or designee. will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

§ 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 review of nursing schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for three of 21 days (24-hour periods) reviewed for December 20 through December 26, 2025; December 31, 2025 through January 6, 2026; and January 23 through January 29, 2026.

Findings include:

Review of the nursing time schedules provided by the facility revealed that the facility provided 3.10 hours of direct care for each resident on December 31; 3.10 hours of direct care for each resident on January 24; and 3.15 hours of direct care for each resident on January 25.

Interview with the Nursing Home Administrator on January 30, 2026, at 1:30 p.m. confirmed that the facility did not meet the required daily hours of direct resident care for each resident on the days listed above.

Plan of Correction - To be completed: 03/03/2026

1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met.

2. The facility will continue to take measures to adequately provide staff to meet the minimum required total number of hours for general nursing care provided in each 24 hour period. The Nursing Home Administrator, or designee, will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler, who are responsible to maintain adequate staffing.

3. The Nursing Home Administrator, or designee, will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months.

4. Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meeting.

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