Pennsylvania Department of Health
 RIVERTON REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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RIVERTON REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  123 surveys for this facility. Please select a date to view the survey results.

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RIVERTON REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, a Civil Rights Compliance survey, and an Abbreviated survey in response to a complaint, completed on December 5, 2025, it was determined that Riverton Rehabilitation and Healthcare 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(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
§483.60(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 observation and staff interview, it was determined that the facility failed to store, prepare, and serve foods in a sanitary manner in the food service department to prevent the potential for foodborne illness.

Findings include:

Observation during the initial kitchen tour on December 3, 2025 at 10:30 a.m., revealed the following:

Inside the stand up freezer, there were two plastic bags of French fries and three additional paper bags of French fries that were not labeled or dated. There was one bag of chicken fingers that was not labeled or dated. There were two containers of ice cream in a plastic bag that were not labeled or dated. There was a white plastic bag of a food item in this same freezer that was not labeled or dated. In this stand up freezer, there was an accumulation of crumbs on the bottom of the freezer.

The convection ovens were very soiled with grease on the doors and the racks. There was an accumulation of burnt crumbs on the bottoms of both of the ovens.
There was an area of a black substance stained on the right side of the back splash of the stove next to the convection ovens.

In the main freezer, there was a package of tortillas that had been opened and re-sealed but was not labeled or dated.

In an interview during the initial tour of the dietary department, the Food Service Director stated that all food items were to be labeled and dated.

28 Pa. Code 201.14(a) Responsibility of Licensee







 Plan of Correction - To be completed: 01/06/2026

1. Upon notification, the food items found on the kitchen tour were discarded on December 3rd, 2025. Also, the freezer, convection oven and backsplash next to the stove were cleaned and debris was removed.

2. An initial audit of kitchen equipment and storage areas was completed to ensure that all areas were cleaned appropriately and free of debris. Also, an initial audit was completed of food storage areas to ensure that open food items were labeled and dated appropriately. Variances were addressed at the time of the audit and placed on the facility audit tool.

3. The NHA/Designee re-educated the Dietary Department on the Policy and Procedures for labeling and dating food as well as cleanliness of kitchen equipment.

4. The NHA/Designee will complete 5 random audits on alternating shifts of the kitchen equipment and storage areas to ensure that open food is labeled and dated appropriately, and that kitchen equipment and kitchen areas are free of debris, soiling and stains three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.
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 a clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 21 sampled residents. (Residents 7 and 109)

Findings include:

Clinical record review revealed that Resident 7 had diagnoses that included diabetes mellitus. A physician's order dated October 9, 2025, directed staff to weigh the resident every two weeks. A review of the Medication Administration Record (MAR) for October 2025 and November 2025 revealed that there was no evidence that staff weighed Resident 7 as ordered.

Clinical record review revealed that Resident 109 had diagnoses that included hypertension (high blood pressure) and chronic systolic (congestive) heart failure. On November 6, 2025, the physician ordered that staff weigh Resident 109 daily for four weeks, ending December 5, 2025, and every Monday, Wednesday, and Friday thereafter, for treatment of congestive heart failure, and notify the physician if the resident gained more than two pounds (lbs.) in 24 hours or five pounds in a week. Review of Resident 109's MAR for November and December 2025, revealed that staff failed to weigh the resident on November 7, 8, 9, 10, 13, 14, 15, 22, and 27, and December 2, 2025, as ordered.

Review of Resident 109's MAR for November and December 2025, revealed that Resident 109 gained more than two pounds in 24 hours on the following occasions:

November 18-19, 2025: 7.6 lbs. gain
November 25-26, 2025: 6.6 lbs. gain

There was no evidence that the physician had been notified of the weight changes greater than two pounds in 24 hours.

In an interview on December 5, 2025, at 11:44 a.m., the Director of Nursing confirmed that there was no documented evidence that residents 7 and 109 were weighed and that the physician was notified of changes as ordered.

CFR 483.25 Quality of Care
Previously Cited 8/6/25

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






 Plan of Correction - To be completed: 01/06/2026

1. Resident R7 & R109 were re-weighed with no variances noted on 12/5/25.

2. An initial audit was completed of current residents ordered daily and weekly weights to ensure that weights were obtained appropriately and notifications were made as necessary. Variances were addressed at the time of the audit and placed on the facility audit tool.

3. The DON/Designee re-educated licensed nursing staff of the Policy and Procedure for obtaining resident weights and following Physician's orders as written.

4. The DON/Designee will complete 5 random audits of residents receiving daily and weekly weights to ensure weights are obtained appropriately and Physician notifications are completed appropriately three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement an intervention to promote wound healing for one of two sampled residents with skin impairments. (Resident 120)

Findings include:

Clinical record review revealed that Resident 120 was admitted to the facility on December 1, 2025, with diagnoses that included end stage renal disease, anemia, and cirrhosis of the liver. The resident had a stage three pressure ulcer on the right heel. A physician's order dated December 1, 2025, directed staff to apply a heel boot to the right foot every shift. On December 3, 2025, at 10:30 a.m., 11:58 a.m., and 1:00 p.m., the resident was observed in bed; the heel boot was not in place. On December 4, 2025, at 10:45 a.m. and 12:45 p.m., the resident was observed in bed; the heel boot was not in place.

In an interview on December 5, 2025, at 10:25 a.m., the Assistant Director of Nursing (ADON) stated that the heel boot should have been applied as ordered.

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









 Plan of Correction - To be completed: 01/06/2026

1. Resident R120 had a skin check completed to ensure that no alterations in skin integrity were noted with no variances noted on 12/5/2025.

2. An initial audit was completed of current residents ordered heel boots to ensure that the boots were in place as ordered. Variances were addressed at the time of the audit and placed on the facility audit tool.

3. The DON/Designee completed re-education with the Nursing Staff on the Policy and Procedure for following Physician's Orders related to pressure injury prevention

4. The DON/Designee will complete 5 random audits of residents ordered heel lift boots to ensure that the boots are in place appropriately three times per week for two weeks, weekly for four weeks, and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide physician ordered nutritional supplements for three of 21 sampled residents. (Residents 19, 64, 86)

Findings include:

Clinical record review revealed that Resident 19 had diagnoses that included brain compression, cerebral infarction (ischemic stroke), and dysphagia (difficulty swallowing). A physician's order dated November 24, 2025, directed staff to provide a regular diet with nutritional supplementation. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered which included nutritional supplementation three times per day. On December 3, 2025, at 12:18 p.m., the resident was observed eating lunch in the dining room. The meal ticket indicated that the resident was to receive a Mighty Shake, a nutritional supplement, with his meal. There was no Mighty Shake observed. On December 4, 2025, at 12:27 p.m., the resident was observed eating the lunch meal in the dining room. The meal ticket again indicated that the resident was to receive a Mighty Shake with the meal. There was no Mighty Shake observed with the resident's meal.

Clinical record review revealed that Resident 64 had diagnoses that included paraplegia (impairment or loss of motor and sensory function in the lower half of the body), severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). A physician's order dated September 25, 2025, directed staff to provide a regular diet with double portions of protein foods, fortified foods, and nutritional supplementation twice a day. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered which included pudding, yogurt, and fortified foods at meals daily. On December 3, 2025, at 12:26 p.m., the resident was observed eating lunch in the dining room. The meal ticket indicated that the resident was to receive yogurt, pudding, and a Magic Cup, a nutritional supplement, with her meal. There was no yogurt, pudding, or Magic Cup observed with her meal. On December 4, 2025, at 12:23 p.m., the resident was observed eating the lunch meal in the dining room. The meal ticket again indicated that the resident was to receive yogurt, pudding, and a Magic Cup with her meal. There was no yogurt, pudding, or Magic Cup observed with the resident's meal.

Clinical record review revealed that Resident 86 had diagnoses that included chronic obstructive pulmonary disease, dysphagia (difficulty swallowing), and diabetes mellitus. A physician's order dated May 8, 2025, directed staff to provide a regular diet with nutritional supplementation. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered which included nutritional supplementation four times per day. On December 3, 2025, at 12:20 p.m., the resident was observed eating lunch in the dining room. The meal ticket indicated that the resident was to receive a Magic Cup, a nutritional supplement, and chocolate pudding with her meal. There was no Magic Cup or chocolate pudding observed.

In an interview on December 5, 2025, at 11:51 a.m., the Director of Nursing confirmed that residents with physician's orders for nutritional supplements should receive supplements with meals.

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

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







 Plan of Correction - To be completed: 01/06/2026

1. Resident R19, R64, R86 were assessed by the Registered Dietician with no variances noted.

2. An initial audit was completed of current residents receiving nutritional supplements to ensure that the nutritional supplements were received as ordered. Variances were addressed at the time of the audit and placed on the facility audit tool.

3. The NHA/Designee completed re-education with the Dietary staff on the Policy and Procedure for Nutritional Supplements and ensuring accuracy of tray tickets when delivering meals.

4. The NHA/Designee will complete 10 random audits of residents receiving nutritional supplements to ensure that the supplements were delivered as ordered three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations: Based on clinical record review, observation, and interview, it was determined that the facility failed to ensure that residents were served preferred food items and items listed on the menu for three of 21 residents. (Residents 19, 79, 86) In addition, based on review of the current menu, it was determined that the facility failed to serve the residents a food item listed on the menu for one meal on two of three nursing units. (Second and Third floor nursing units) Findings include: Clinical record review revealed that Resident 19 had diagnoses that included brain compression, cerebral infarction (ischemic stroke), and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) assessment, dated October 1, 2025, revealed the resident had no cognitive impairment. A review of Resident 19's care plan revealed he was at risk for malnutrition due to brain compression, cerebral infarction, and dysphagia; and weight changes with an intervention for staff to honor food preferences as able. Review of a nutrition assessment dated November 24, 2025, revealed that the resident was on a regular diet and was able to eat independently once he was set up with his meal. Observation on December 3, 2025, at 12:18 p.m., revealed that the resident was in the dining room and had been served lunch. Review of his meal card indicated that he preferred to have chocolate milk with every meal. He had been served apple juice. At that time, the resident stated that he preferred chocolate milk. Clinical record review revealed that Resident 86 had diagnoses that included chronic obstructive pulmonary disease, dysphagia, and diabetes mellitus. The MDS assessment dated September 17, 2025, revealed the resident had no cognitive impairment. A review of Resident 86's care plan revealed she was at risk for malnutrition due to heart failure, diabetes; and weight changes due to a diuretic regimen with an intervention for staff to honor food preferences as able. Review of a nutrition assessment dated November 18, 2025, revealed that the resident was on a regular diet and was able to eat independently once she was set up with her meal. Observation on December 3, 2025, at 12:20 p.m., revealed that the resident was in the dining room and had been served lunch. Review of her meal card indicated that she preferred to have chocolate milk with every meal. She had been served apple juice. At that time, the resident stated that she preferred chocolate milk. Clinical record review revealed that Resident 79 had a diagnosis of diabetes. A review of the care plan revealed that the resident was at risk for malnutrition due to advanced age and chronic kidney disease. There was a current intervention for staff to honor her food preferences. Review of a nutrition assessment dated November 11, 2025, revealed that the resident was on a regular diet and was able to eat independently once she was set up with her meal. Observation on December 4, 2025, at 9:18 a.m., revealed that the resident was in her room in bed and had been served her breakfast. Review of her meal tray card indicated that she preferred to have apple juice. She had been served orange juice. At this time, the resident stated that she preferred apple juice over orange juice. Review of the facility menus revealed the lunch meal on Wednesday, December 3, 2025, was to include Maryland-style crab cakes, Old Bay seasoned fries, cucumber dill salad, and assorted cookies. Observation on December 3, 3025, at lunch time, 12:00 p.m., on the second floor, revealed that residents did not receive the cucumber dill salad with their regular meal. Observation on December 3, 3025, from 12:15 p.m. through 12:40 p.m., in the third-floor dining room, revealed that the meal should have included cucumber dill salad, and the residents received no salad and no substitution for the salad. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b) Management.
 Plan of Correction - To be completed: 01/06/2026

1. The facility is unable to retroactively correct the meal trays for residents R19, R86, R79 noted on December 3rd and 4th.

2. An initial audit of current residents' meal preferences to ensure that the resident's tray tickets reflected their current preferences accurately. Variances were addressed at the time of the audit and placed on the facility audit tool.

3. The NHA/Designee completed re-education with the Dietary staff on the Policy and Procedure for resident food preferences and ensuring accuracy of tray tickets when delivering meals.

4. The NHA/Designee will complete 10 random observational audits of current resident meal trays on alternating meals to ensure that the residents receive their preferences on the meal trays and what is written on the menus appropriately three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

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