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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Complaint Survey completed on June 26, 2026, it was determined that Titusville Nursing and Rehab 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:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policy, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed toensure appropriate safety measures were implemented regarding the service of hot coffee to a resident that resulted in an accident and actual harm of a second degree skin burn (a burn that damages the top layer of skin and damages the second layer of skin) for one of 20 residents reviewed (Resident R28). This deficiency is cited as past non-compliance.

Findings include:

The "Hot Liquids Policy-Food Service" policy, dated 4/23/26, states, "To ensure that all hot liquids served within the facility are delivered at a temperature that balances safety and palatability, while also considering the unique needs and physical capabilities of each resident ...All coffee and hot liquids will be brewed in the main kitchen ...The temperature of hot liquids will be recorded and will not exceed 145 degrees at the point of service ...Cups must be appropriate for the resident's ability-lightweight, easy to grip, and if necessary, fitted with lids or handles to prevent spills."

Resident R28's clinical record revealed an admission date of 12/7/22, with diagnoses that included Alzheimer's Disease (a progressive disorder that affects memory, thinking, and behavior), absence epileptic syndrome not intractable without status epilepticus (seizures that cause brief sudden staring spells-that is well controlled with medications), hypertension (high blood pressure).

Review of the clinical record revealed Resident R28 had a BIMS (brief interview for mental status) score of seven dated 2/20/26. The BIMS tool is used to assess cognitive function; a score of seven indicates a severe impairment.

Resident R28's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E3, dated 2/26/26, at 6:34 a.m. "CNA (Certified Nursing Assistant) called this writer to the room, resident spilled hot coffee on her thigh. 9cm (centimeters) by 8cm redness noted to left thigh loose skin from possible blistering gave resident Tylenol for pain."

Resident R28's clinical record revealed a nursing note written by the Director of Nursing (DON), dated 2/26/26, at 8:30 a.m. "Medical Director in facility and assessed resident's burn area ..."

Resident R28's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E4, dated 2/26/26, at 2:35 p.m. " ...Spilling coffee on lap ...LT (left thigh) ...LG (large) red area noted with scattered blistering ..."

Resident R28's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E5, dated 2/26/26, at 10:30 p.m. "LT one large blister has broke and others are starting to leak ..."

The facility investigation revealed that LPN Employee E3 provided a written statement with an incident date of 2/26/26, and time of 5:25 a.m. which revealed, "CNA called me to Resident R28's room. Stated a cup of hot coffee spilled on Resident R28's leg ..."

The facility investigation revealed that CNA Employee E6 provided a written statement with an incident date of 2/26/26, and time of 5:25 a.m. which revealed, "Got Resident R28 washed and dressed for the day. Asked [him/her] if he/she would like a cup of coffee, went and got one. [He/She] ended up spilling it on his/her leg."

Documentation submitted by the facility, dated 2/26/26, revealed that " ...the coffee was obtained from the employee breakroom in a Styrofoam cup... [Resident R28] unable to say exactly what happened after being interviewed ..."

The facility failed to ensure that Resident R28 was provided with a hot liquid served at a safe temperature, from the facility's main kitchen, was served in an appropriate container, and failed to properly supervise Resident R28 with a hot liquid causing second degree burns to his/her left thigh.

This deficiency is cited as past non-compliance.

On 2/26/26, the facility-initiated education for all staff to ensure that residents are receiving coffee at safe temperatures from the main kitchen, in an appropriate container, and are properly supervising residents. This plan includes the following:

Immediate Suspension of CNA Employee E6.

Immediate education regarding checking temperatures, obtaining hot liquids from the main kitchen, ensuring hot liquids are in an appropriate container, and that residents are properly supervised when drinking hot liquids was provided to all staff, which occurred from 2/26/26, through 3/15/26.

Review of all residents at risk related to hot liquids completed by the DON and care plans updated as indicated.

Interviews with CNA Employees E7 and E8, LPN Employees E4 and E9, RN Employee E10, Housekeeping Employee E11 ,Therapy Director, Activities Director, Dietary Manager, Laundry Supervisor, Medical Records Manager, and Business Manager, all confirmed the facility-initiated education and competencies starting 2/26/26, which included education on checking temperatures for hot liquids, obtaining hot liquids from the main kitchen, ensuring hot liquids are in an appropriate container, and that residents are properly supervised when drinking hot liquids.

Audits were conducted to ensure residents receive hot liquids at appropriate temperatures, from the main kitchen, in an appropriate container, and are properly supervised, which occurred on all shifts and on all units from 2/26/26, through 3/19/26, with all performed appropriately.

The facility has demonstrated compliance with hot liquids since 3/19/26.

During an interview with the DON on 6/26/26, at approximately 12:00 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from harm/injury regarding hot liquids and had achieved substantial compliance.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(1) Management

28 Pa. Code 211.12(c) Nursing services

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

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

Plan of Correction - To be completed: 07/14/2026

Past noncompliance: no plan of correction required.

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

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(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 review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety and serve food in a safe and sanitary manner during tray line in the main kitchen.

Findings include:

Review of facility policy entitled "Food Safety Requirements" dated 4/23/26, indicated "Staff shall adhere to safe hygienic practices to prevent contamination of food from hands or physical objects."

Review of facility policy entitled "Date Marking for Food Safety" dated 4/23/26, indicated "The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded." And "The marking system shall consist of, the day/date of opening, and the day/date the item must be consumed or discarded."

Observations during the initial kitchen tour on 6/23/26, between 9:45 a.m. and 10:00 a.m. revealed in the walk-in refrigerator an open container of garlic with a use by date of 5/9/26. In the upright freezer there was an open bag of waffles that was not closed, four packages of hot dog buns with a best by date of 5/26/26, and four packages of English muffins which appeared freezer burnt and had no date indicating when they should be discarded. In the dry storage area, there were three open packages of pasta, one with a use by date of 6/6/26, one with no open or use by date and one with no use by date.

During an interview at the time of observations the Dietary Manager confirmed the open container of garlic, hot dog buns, English muffins, and three packages of pasta were beyond their use by dates and/or lacked dates. He/she confirmed that the open bag of waffles was not properly closed to prevent contamination and that all the items should have been discarded by or before their use by date or expiration date.

Observations during tray line on 6/24/26, at approximately 11:20 a.m. revealed that Dietary Cook Employee E2 was observed with gloved hands touching the outside of the refrigerator, countertop, oven door and the food transport cart (a cart that meal trays for residents are placed in to take out of the kitchen). He/she then picked up and placed a hamburger bun on a plate with their hands, then placed a hamburger on the bun and proceeded to pick up a slice of cheese with their hands and placed it on top of the hamburger. Dietary Cook Employee E2 did not remove his/her gloves and perform hand hygiene during the entire process.

During an interview at the time of observations the Dietary Manager confirmed that Employee E2 touched several items then touched the resident's food with the same gloves. He/she also confirmed that Employee E2 should have removed his/her gloves, washed his/her hands and applied new gloves before touching the resident's food.

28 Pa. Code 211.6(c)(f) Dietary services

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management

Plan of Correction - To be completed: 07/28/2026

The Dietary Manager discarded the outdated food upon notification.

The Dietary Manager conducted an audit of all facility food storage to ensure that unlabeled and out-of-date food was discarded.

Dietary Manager to educate dietary department staff on facility policy titled "Date Marking for Food Safety" as well as "Food Safety Requirements".

The Dietary Manager or designee will audit all facility food storage including all pantry and resident refrigerators to ensure proper labeling and dating of food and proper safe hygienic practices by dietary staff five times a week for two weeks, once weekly for two weeks, and once monthly for three months. Audits to include breakfast, lunch, and dinner. The results of these audits will be reviewed by the Quality Assurance & Performance Improvement committee for three months with appropriate follow up as needed.

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

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(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 policy and clinical records, observations, and staff interviews, it was determined that the facility failed to receive instructions for removal of a urinary catheter (a soft plastic tubing inserted into the bladder to drain urine into a bag) in a timely manner for one of one residents reviewed for catheters (Resident R30).

Findings include:

Review of facility policy entitled "Appropriate Use of Indwelling Catheters" dated 4/23/26, indicated "Indwelling urinary catheters will be used on a short-term basis ..., The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the insertion, continuation, or removal of an indwelling urinary catheter."

Review of Resident R30's clinical record revealed an admission date of 4/29/26, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and chronic obstructive pulmonary disease (when your lungs do not have adequate air flow).

Review of Resident R30's clinical record revealed an order from urology dated 6/9/26, instructing to remove his/her urinary catheter for a trial to void(a procedure where the urinary catheter is removed to see if the person will urinate without the urinary catheter) attempt. Monitor patient for six hours following the catheter being discontinued if no void- straight catheter (a urinary catheter that does not remain in the patient's body) the patient. If greater that 350 ml (milliliters) of urine retained leave indwelling catheter and reach out to the urology team for the next steps.

Review of Resident R30's progress notes revealed the following notes:
note dated 6/9/26, at 2:37 p.m. indicating urology wanted to do a trial voidnoted dated 6/9/26, at 7:18 p.m. catheter was reinserted per resident's request.note on 6/10/26, at 10:50 a.m. revealed urology updated on urinary catheter and will call back with further instructions.Progress notes lacked evidence that the facility followed up with urology for further instructions for the potential removal of Resident R30's urinary catheter in a timely manner.

During an interview on 6/25/26, at 12:10 p.m. Registered Nurse (RN) Employee E1 confirmed there was no evidence that the facility followed up with urology for further instructions for Resident R30's urinary catheter and on 6/26/26, at 9:30 a.m. RN Employee E1confirmed that the facility failed to follow-up with urology for further instructions regarding Resident R30's urinary catheter in a timely manner, and that the facility should have reached out to urology in a timely manner.

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

28 Pa. Code 211.10(c) Resident care policies

Plan of Correction - To be completed: 07/28/2026

Resident's urologist was contacted on 6-25-26 with appointment set up for July 1, 2026.

Facility conducted an audit of all residents with indwelling urinary catheters to verify physician orders for catheter type/frequency of change are current. Confirmed no other residents have overdue urology appointments.

In-service education provided to licensed nursing staff on facility policy for catheter management and specialist follow up utilizing follow up appointment form.

Appropriate use of Indwelling catheter including follow-up with urology appointments and recommendations audit will be completed on all residents with catheters five times a week for 2 weeks, then weekly times 2 weeks and monthly thereafter by Director of Nursing or designee. Results will be reported to Quality Assurance & Performance Improvement committee monthly for 3 months for any identified issues and follow up needed.

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