Phoebe Richland HCC

In the surveyor’s words

From the most serious findings on record at Phoebe Richland HCC, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Apr 14, 2021

  Based on facility policy review, observations, interviews, and review of manufacturer's instructions it was determined that the facility failed to maintain medication storage in three of three medications carts (Gateway, Gateway West and Springhouse D2), and one of three medication storage rooms (Gateway). Findings Include: Review of the facility policy entitled Medication Administration-General Guidelines, dated [DATE], revealed that medications were to be dated when opened and should be discardred when expired. Observation of the Gateway West medication cart on [DATE], at 10:08 a.m., revealed one open [MEDICATION(S)] injection pen (insulin) and one Amelog injection pen (insulin) with no identified open or expiration date. […]

• No harm, potential for more than minimal, isolatedF550Feb 19, 2026

  Based on clinical record review and observation, it was determined that the facility failed to ensure that dignity was maintained for one of 26 sampled residents. (Resident 126)Findings include: Clinical record review revealed that Resident 126 had diagnoses that included parkinsonism, urinary retention, and hypotension. On February 12, 2026, the physician ordered for the resident to have an indwelling catheter for urination. Observations on February 17, 2026, from 12:04 p.m. through 12:35 p.m., and February 18, 2026, from 11:59 a.m. through 12:30 p.m., revealed Resident 126 sitting in a wheelchair in the dining room. The Foley catheter bag was not covered and contained urine. Multiple residents and staff were present in the area during those time periods. […]

• No harm, potential for more than minimal, isolatedF641Feb 19, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the residents' current status for two of 26 sampled residents. (Residents 4, 28) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included atherosclerotic heart disease, heart failure, and cerebral infarction (stroke). The MDS assessment dated [DATE], incorrectly indicated in Section H (Bladder and Bowel) that Resident 4 had an indwelling catheter. […]

• No harm, potential for more than minimal, isolatedF656Feb 19, 2026

  Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 26 sampled residents. (Residents 42, 108)Findings include: Clinical record review revealed that Resident 42 was admitted to the facility on [DATE], and had diagnoses that included displaced right femur fracture, anxiety, and dementia. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated January 27, 2026, noted that the resident's psychotropic drug use was to be addressed in the care plan. […]

• No harm, potential for more than minimal, isolatedF688Feb 19, 2026

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further limitations in range of motion for one of six sampled residents who required use of a splint and/or had limitations in range of motion. (Resident 7)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included a stroke with paralysis on the right side. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, required assistance with dressing, and had impairment in range of motion on both sides of the upper and lower extremities. On April 29, 2025, a physician ordered for staff to apply a resting hand splint to the right hand after morning care. […]