Pennsylvania Department of Health
NORRITON SQUARE NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NORRITON SQUARE NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 137 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.


NORRITON SQUARE NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey and State Licensure Survey, and an Abbreviated Survey in response to a complaint, completed on January 23, 2026, it was determined that Norriton Square Nursing and Rehabilitation Center, was not in compliance with the 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 related to the health portion of the Survey Process.

Plan of Correction:

483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel:

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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

§483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii).

Observations: Based on reviews of the established meal delivery schedule, interviews with dietary staff, observations of the food and nutrition services on the nursing units and a review of the dietary staffing schedules for the kitchen, it was determined that the facility failed to employ sufficient staff to carry out the functions of the dietary services department. Findings include: During the sanitation inspection of the main kitchen at 10:00 a.m., on January 20, 2026, the director of dietary services, Employee E7, reported that there were two dietary staff members that had called out of work on January 20, 2026. The only dietary staff working on January 20, 2026, were the director of dietary services, Employee E7, the cook, Employee E20 and a dietary aide, Employee E9. A review of the established meal delivery schedule from the food and nutrition services revealed that the third floor was to receive a meal cart at 11:40 a.m., and 11:50 a.m., daily and the dining room was to receive a food cart between noon and 1:00 p.m. A review of the established meal delivery schedule from the food and nutrition services revealed that the second-floor nursing unit was to receive a meal cart at 11:25 a.m., and 11:35 a.m. daily. Observations of the noon meal service on the second and third floor nursing unit revealed that the food carts containing the noon meals for the residents were not arriving to the nursing units in a timely manner. Observations on the third-floor nursing unit revealed that the food carts for the residents living on the A hall did not arrive on the nursing unit until 12:55 p.m. and the food carts for B hall did not arrive on the nursing unit until 1:00 p.m., on January 20, 2026. Observations on the second-floor nursing unit revealed that the food carts for the residents living on the A hall did not arrive on the nursing until 1:10 p.m., and the food carts for the B hall did not arrive until 1:15 p.m., on January 20, 2026. The late delivery of foods/meal trays for lunch on January 20, 2026, was attributed to the staffing shortages in the food and nutrition department. Interview with the director of dietary services, Employee E7, at 1:30 p.m., confirmed that the food and nutrition services department had insufficient support personnel to effectively carry out meal preparations, delivery and service of foods and beverages according to the facility's scheduled time for meals. A review of the dietary staffing schedules for January 14, 2026, through January 20, 2026, revealed that the food and nutrition services department staff had been calling out of work regularly for the week reviewed. Interview with the administrator, Employee E1 at 2:00 p.m., on January 21, 2026, confirmed the lack of dietary staff employees to effectively and safely carry out the functions of the dietary services. 28 PA. Code 201.14 (a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(e)(1)(3) Management

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

All residents received nutrition in accordance with their plan of care and attending physician orders; there have been no adverse events due to staffing.
The dietary manager and NHA review the schedule daily. In the event of call-offs, the facility follows staffing policies, including exhausting all possible replacements from the internal staffing pool. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions.
Dietary Staff have been re-educated on the staffing requirements and the importance of maintaining the schedule as posted.
To monitor and maintain ongoing compliance, the DM or designee will audit staffing weekly x4 weeks, then monthly for two months.
The results of these audits will be reviewed during the monthly QAPI meeting x 3 months

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

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.

§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;

Observations: Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Resident R65). On January 21, 2025, at 9:30 a.m., review of physician orders for Resident R74 indicated orders for the following among other medications: Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth one time a day for HTN (Ordered on July 25, 2025)Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour (Venlafaxine HCl), give 150 mg by mouth one time a day for depression (Ordered on July 25, 2025)Aspercreme Lidocaine External Cream 4 % (Lidocaine HCl), Apply to neck topically two times a day for pain (Ordered on August 11, 2025)Pataday Ophthalmic Solution 0.2 % (Olopatadine HCl), Instill 1 drop in both eyes one time a day for eye irritation (Ordered on September 5, 2025)Meloxicam Tablet 7.5 MG, give 1 tablet by mouth one time a day for OA (Ordered on October 3, 2025).On January 21, 2025, at 9:39 a.m., observed that Employee E18, a Licensed Nurse, decanted Lisinopril Oral Tablet 20 MG; Venlafaxine HCl,150 MG, Oral Capsule Extended Release; Meloxicam Tablet 7.5 MG into a medicine Disposable cup. Along with these medications, E18 gathered Aspercreme Lidocaine External Cream 4 %, and Pataday Ophthalmic Solution 0.2 %. E18 then approached Resident R65 in the resident room and checked R65's Blood Pressure. After noting the Blood pressure of R 65, E18 attempted to administer the gathered medications to R65, without verifying the identity of R65. At that moment, before administering the medications to R65, E18 was prevented from administering those medications to R65, as those medications were intended for R74, not for R65. Review of literature revealed as follows: Lisinopril 20 mg oral tablet is a commonly prescribed medicine to treat high blood pressure (hypertension); Venlafaxine HCl ER (extended-release) oral capsule is an antidepressant used to treat major depressive disorder (MDD), generalized anxiety disorder (GAD), social anxiety disorder, and panic disorder; Meloxicam 7.5 mg tablet is an anti-inflammatory drug prescribed to relieve pain, swelling, and stiffness from osteoarthritis, rheumatoid arthritis; Aspercreme Lidocaine External Cream 4% is a maximum-strength, topical analgesic used to temporarily relieve minor pain in muscles and joints, including backaches, arthritis, by using lidocaine to block pain signals; and Pataday Ophthalmic Solution 0.2% is an antihistamine used to treat itching and redness in the eyes caused by allergies. At the time of the observation, interview with Employee E18 confirmed the above findings. The facility incurred a medication error rate of 13.79%. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

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

Resident R65 did not receive R74 medications.
E18 was educated on Medication Administration Policy with a focus on verifying resident identification prior to administration, and a medication administration competency was conducted.
The DON or designee will re-educate licensed nursing staff on Medication Administration with a focus on verifying resident identification prior to administering medications to prevent medication errors.
The DON or designee will perform medication administration competencies for all licensed nurses to ensure resident identification is verified prior to medication administration to prevent medication errors.
The DON or designee will conduct 3 weekly random audits of medication administration passes on random shifts x 12 weeks to ensure resident identity was verified prior to medication administration.
The results of these audits will be reviewed during the monthly QAPI meeting x 3 months

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations: Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for one of four residents observed during medication administration observation, resulting in significant medication error (Residents R65). Findings Include: On January 21, 2025, at 9:30 a.m., review of physician orders for Resident R74 indicated orders for the following among other medications: Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth one time a day for HTN (Ordered on July 25, 2025) Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour (Venlafaxine HCl), give 150 mg by mouth one time a day for depression (Ordered on July 25, 2025) Aspercreme Lidocaine External Cream 4 % (Lidocaine HCl), Apply to neck topically two times a day for pain (Ordered on August 11, 2025) Pataday Ophthalmic Solution 0.2 % (Olopatadine HCl), Instill 1 drop in both eyes one time a day for eye irritation (Ordered on September 5, 2025) Meloxicam Tablet 7.5 MG, give 1 tablet by mouth one time a day for OA (Ordered on October 3, 2025). On January 21, 2025, at 9:39 a.m., observed that Employee E18, a Licensed Nurse, decanted Lisinopril Oral Tablet 20 MG; Venlafaxine HCl,150 MG, Oral Capsule Extended Release; Meloxicam Tablet 7.5 MG into a medicine Disposable cup. Along with these medications, E18 gathered Aspercreme Lidocaine External Cream 4 %, and Pataday Ophthalmic Solution 0.2 %. E18 then approached Resident R65 in the resident room and checked R65's Blood Pressure. After noting the Blood pressure of R 65, E18 attempted to administer the gathered medications to R65, without verifying the identity of R65. At that moment, before administering the medications to R65, E18 was prevented from administering those medications to R65, as those medications were intended for R74, not for R65. Review of literature revealed as follows: Lisinopril 20 mg oral tablet is a commonly prescribed medicine to treat high blood pressure (hypertension); Venlafaxine HCl ER (extended-release) oral capsule is an antidepressant used to treat major depressive disorder (MDD), generalized anxiety disorder (GAD), social anxiety disorder, and panic disorder; Meloxicam 7.5 mg tablet is an anti-inflammatory drug prescribed to relieve pain, swelling, and stiffness from osteoarthritis, rheumatoid arthritis; Aspercreme Lidocaine External Cream 4% is a maximum-strength, topical analgesic used to temporarily relieve minor pain in muscles and joints, including backaches, arthritis, by using lidocaine to block pain signals; and Pataday Ophthalmic Solution 0.2% is an antihistamine used to treat itching and redness in the eyes caused by allergies. At the time of the observation, interview with Employee E18 confirmed the above findings. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

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

Resident R65 did not receive R74 medications.
R65 and R74 received their medications as ordered.
E18 was re-educated on Medication Administration Policy with a focus on verifying resident identification prior to administration, and a medication administration competency was conducted.
The DON or designee will re-educate licensed nursing staff on Medication Administration with a focus on verifying resident identification prior to administering medications to prevent medication errors.
The DON or designee will perform medication administration competencies for licensed nurses to ensure resident identification is verified prior to medication administration to prevent medication errors.
The DON or designee will conduct 3 weekly random audits of medication administration passes on each unit x 12 weeks to ensure resident identity was verified prior to medication administration.
The results of these audits will be reviewed during the monthly QAPI meeting x 3 months

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 policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of 32 Residents reviewed (R44). Findings Include: Review of Resident R44's clinical record revealed that the resident was admitted to the facility on December 3, 2025, with diagnoses that included Encephalopathy (Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure), Anxiety disorder (Anxiety disorders are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), Bipolar disorder (Bipolar disorder is a mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), Chronic Pain Syndrome (A condition where pain persists for 36 months or longer, typically extending beyond the expected healing time of an initial injury or illness) , and Depression (Depression is a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and, in many cases, significant physical, cognitive, and emotional impairment). Review of physician order for R44, dated January 9, 2026, indicated an order for " Wander Guard/Wander Elopement Device due to poor safety awareness, every shift check the placement of the device and in supplemental document the location; and every night shift check function and document in supplemental documentation; Expiration date: June 2027; update the order with the new date when the bracelet is changed". Review of the care plan for R44, on January 22, 2026, at 10:11 a.m., revealed that there were no focus, outcomes (goals), and interventions, care- planned for Wander Guard/Wander Elopement Device administration. on January 22, 2026, at 10:24 a.m., interview with the DON confirmed the above findings. 28 Pa Code 211.10 (c)(d) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

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

Resident R44's elopement care plan was developed and includes the focus, goals, and interventions.
The DON/designee will conduct an initial audit of current residents with orders for a secure care device to ensure that an elopement care plan, including focus, goals, and interventions, has been developed.
The DON or designee will re-educate licensed nursing staff on the Person Centered Careplan policy with the focus on residents at risk of elopement..
The DON or designee will conduct weekly random audits of 5 residents X 12 weeks to ensure residents with a secure care device have a comprehensive care plan to address their elopement risk.
The results of these audits will be reviewed during the monthly QAPI meeting x 3 months.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations: Based on observation, clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to adhere to acceptable standards of nursing practice related to medication administration for one of four residents observed during medication administration (Resident R65). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11(b), General Functions of the Registered Nurse (RN), and 21.14(a), Administration of Drugs, indicated that the RN is fully responsible for all actions as a licensed nurse and is accountable to patients for the quality of care delivered, and administers medication ordered for the patient in the dosage and manner prescribed. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145(a)(b), Functions of the Licensed Practical Nurse (LPN), indicated that the LPN functions as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency, and administers medication ordered for the patient. On January 21, 2025, at 9:30 a.m., review of physician orders for Resident R74 indicated orders for the following among other medications: Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth one time a day for HTN (Ordered on July 25, 2025) Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour (Venlafaxine HCl), give 150 mg by mouth one time a day for depression (Ordered on July 25, 2025) Aspercreme Lidocaine External Cream 4 % (Lidocaine HCl), Apply to neck topically two times a day for pain (Ordered on August 11, 2025) Pataday Ophthalmic Solution 0.2 % (Olopatadine HCl), Instill 1 drop in both eyes one time a day for eye irritation (Ordered on September 5, 2025) Meloxicam Tablet 7.5 MG, give 1 tablet by mouth one time a day for OA (Ordered on October 3, 2025). On January 21, 2025, at 9:39 a.m., observed that Employee E18, a Licensed Nurse, decanted Lisinopril Oral Tablet 20 MG; Venlafaxine HCl,150 MG, Oral Capsule Extended Release; Meloxicam Tablet 7.5 MG into a medicine Disposable cup. Along with these medications, E18 gathered Aspercreme Lidocaine External Cream 4 %, and Pataday Ophthalmic Solution 0.2 %. E18 then approached Resident R65 in the resident room and checked R65's Blood Pressure. After noting the Blood pressure of R 65, E18 attempted to administer the gathered medications to R65, without verifying the identity of R65. At that moment, before administering the medications to R65, E18 was prevented from administering those medications to R65, as those medications were intended for R74, not for R65. Review of literature revealed as follows: Lisinopril 20 mg oral tablet is a commonly prescribed medicine to treat high blood pressure (hypertension); Venlafaxine HCl ER (extended-release) oral capsule is an antidepressant used to treat major depressive disorder (MDD), generalized anxiety disorder (GAD), social anxiety disorder, and panic disorder; Meloxicam 7.5 mg tablet is an anti-inflammatory drug prescribed to relieve pain, swelling, and stiffness from osteoarthritis, rheumatoid arthritis; Aspercreme Lidocaine External Cream 4% is a maximum-strength, topical analgesic used to temporarily relieve minor pain in muscles and joints, including backaches, arthritis, by using lidocaine to block pain signals; and Pataday Ophthalmic Solution 0.2% is an antihistamine used to treat itching and redness in the eyes caused by allergies. At the time of the observation, interview with Employee E18 confirmed the above findings. The facility incurred a medication error rate of 13.79%. The facility failed to adhere to acceptable standards of nursing practice related to medication administration. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.12(d)(3)(5) Nursing services.

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

Resident R65 did not receive R74 medications.
R65 and R74 received their medications as ordered.
E18 was re-educated on Medication Administration Policy with a focus on verifying resident identification before administration, and a medication administration competency was conducted.
The DON or designee will re-educate licensed nursing staff on Medication Administration with a focus on verifying resident identification before administering medications.
The DON or designee will perform medication administration competencies for licensed nurses to ensure resident identification is verified before medication administration
The DON or designee will conduct 3 weekly random audits of medication administration passes on random shifts x 12 weeks to ensure resident identity was verified before medication administration
The results of these audits will be reviewed during the monthly QAPI meeting x 3 months

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:

§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.

Observations:

Based reviews of policies and procedures, clinical record reviews, observations of care and services, interviews with residents, staff and family members, it was determined that for one of four residents reviewed for emotional behavior, sensory, communication and dignity, the facility failed to ensure a fully functioning hearing device was available and used according to audiology assessment and care planning. (Resident R86)

A review of the facility policy titled consultant agreements and responsibilities revealed that the facility was responsible for making arrangements for care and services for the residents that the facility does not employ as staff through a qualified professional outside service. According to the contract the consulting services were to be timely and the service was to be reported to the administrator through dated signed reports, implementation of plans and continued assessment of the resident.

Observations of Resident R86 during the days of the survey, January 20, 2026, and January 22, 2026, revealed that the resident was in her room in a geriatric reclining chair. The resident was heard yelling out persistently.

Residents R 58, R7, R92, R68, R84, and R72 living on the third-floor nursing unit reported that they were concerned for Resident R86. The residents reported being worried about resident R86thinking that she sounded distressed or in need of help. The residents also reported that the constant yelling, by Resident R86 was annoying for them. The residents were asking, could something be done to help the quality of life for Resident R86.

Interviews with nursing staff revealed that Employee E11 and Employee E14 at 1:45 p.m., on January 20, 2026, revealed that Resident R86 would not yell if you spent time with her one on one. The nursing assistant, Employee E11 reported that it was difficult for her to meet the needs of Resident R86 with one-on-one daily since she had other residents that she had other residents that she was assigned to take care daily.

Interview with the recreational activity's director, Employee E6 at 1:00 p.m., on January 21, 2026, revealed that Resident R86 had a difficult time hearing the rosary prayers being recited in the activities area. The director of activities reported that the amplification device that resident R86 had been issued was not picking up the sounds of the rosary session.

Clinical record review revealed a comprehensive admission assessment MDS (an assessment of care needs) dated August 6, 2025, that indicated Resident R86 had a hearing aid or other hearing appliance. The assessment also indicated that this resident had non-Alzheimer's dementia, legal blindness and anxiety disorder.

Clinical record review for resident R86 revealed a comprehensive quarterly assessment dated December 3, 2025, that indicated this resident had highly impaired hearing. The assessment also said that this resident had cognitive skills that were modified (some difficulty in new situations only).

Clinical record review revealed a psychiatrist progress note dated January 15, 2026, that indicated Resident R86 was persistently yelling, agitated cursing and statements of verbal aggression. The note indicated that the nursing staff were reporting that Resident R86 was still yelling, agitated and irritated.

Clinical record review revealed an activity assessment that indicated that Resident R86's poor hearing affects her participation in the Rosary and Prayer, which she prefers to do.

Clinical record review for Resident R86 revealed a care plan that indicated audiology assessment and care planning as needed and the use of an amplifier device. Clinical record review revealed an audiology consult dated December 31, 2025, that indicated Resident R86 was assessed with moderate to severe hearing loss bilaterally. The audiologist indicated that an amplification device or hearing aid was recommended for both ears. The audiologist indicated that the family would be consulted about what hearing aid (hearing aid or other hearing appliances) was best suited for this Resident R86. There was no documentation to indicate that the audiologist had spoken to the resident's responsible party as care planned about the assessment and recommendations on December 31, 2025, for hearing aids or a hearing device for Resident R86.

Observations of Resident R86 with nursing assistant, Employee E11 at 10:30 a.m., on January 23, 2026, revealed that the amplification device used for Resident R86 was not consistently picking up on sound through the speaking component used by staff and visitors to communicate with this resident. The nursing assistant reported that at varies times when she tries to speak to Resident R86 with the hearing device, the device echoes her voice in the earphones. Observations of the battery holder for the hearing device revealed the batteries were being taped so that the batteries would not fall to the floor. The plastic used to secure the batteries was missing.

Interview with the responsible party for Resident R86 at 2:00 p.m., on January 22, 2026, revealed that Resident R86 does not have hearing aids for her hearing deficits. The family member reported that she would be willing to try hearing aids or other hearing appliances to improve the quality of communication, hearing and quality of life for Resident R86.

28 PA. Code 211.10(a)(b)(c)(d) Resident care policies
28 PA. Code 211.12(d)(1)(3)(5) Nursing services
28 PA. Code 201.14(a) Responsibility of licensee
.

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

Resident R86's responsible party will be consulted regarding their preference for whether a hearing aid or appliance is best suited for the resident. Audiology will be updated as indicated.
The Director of Nursing or Designee will conduct an initial audit of current residents with a hearing device to verify their hearing device is fully functional, an audiology evaluation has been conducted, and recommendations discussed with the resident, RP, and documented.
The Director of Nursing will re-educate licensed nurses on ensuring residents with a hearing device are fully functional, and residents recently seen by audiology have their recommendations discussed with the resident and RP and documented.
The Director of Nursing or designee will conduct weekly audits of 3 residents x 12 weeks to verify hearing devices are functional, recent audiology consults were reviewed and discussed with the resident and RP
DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.

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 upon review of clinical records, interviews with staff and residents and reviews of policies and procedures, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow the physician's orders for daily weights for one of twenty-two residents reviewed. (Resident R35) Findings Include: Review of facility policy titled, "Weights and Heights" with a revision date of June February 1, 2023 states, "Obtaining and Documenting Weight- 1.1.4 If the body weight is not as expected, re-weigh the patient". Resident R35 was admitted to the facility July 1, 2025 with the following diagnosis: Hypertension (a chronic condition where blood forces against artery walls is consistently too high), Pressure Ulcer Stage 2 (a partial-thickness skin loss involving the epidermis and dermis), Anemia (a condition where your blood lacks enough healthy red blood cells to carry adequate oxygen to your body's tissues), Heart Failure (a chronic, manageable condition where the heart cannot pump enough blood to meet the body's needs, often causing fatigue, fluid buildup, and shortness of breath), and Dysphagia (difficulty swallowing). Review of Resident R35's clinical record revealed the resident had a physician order for , "Daily weight-Notify the provider if: gain over 2 pounds in 1 day or 5 pounds in a week" that was dated and started on December 23, 2025. Review of the facility Weights and Vitals log revealed no daily weight on the following dates: December 26, December 27, December 30, January 1, January 3, January 4, January 5, January 8, January 9, January 10, January 13, January 14, January 15, January 17, January 18, and January 19. Further review of the resident's clinical record revealed no documentation that the physician was ever notified of the weight increase on January 16, 2025. Further review of the resident clinical record revealed no re-weight to ensure accurate weight on January 16, 2026. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

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

Resident 35 had not suffered any adverse effects
The Director of Nursing or designee will conduct an initial audit of current residents with physician orders for daily weights to verify that the daily weight was obtained, and the MD was notified if the weight increased outside of parameters.
The DON or designee will re-educate licensed nurses on Weight Policy with the focus on obtaining daily weights as per the physician orders, and MD notification if the weight increases outside of parameters.
The DON or designee will conduct weekly random audits of 5 residents per week x 12 weeks to ensure residents with an order for daily weights were obtained, and the MD is notified if the weight increases outside of parameters
DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.

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

§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 observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to medications found at bedside for one of twenty-two residents reviewed. (Resident R3) Findings Include: Review of facility policy titled, "Medication Administration" with a date of 2007 states, "Policy- Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication." Further review of the Medication Administration policy revealed, "Medication Administration4. Medications are administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose." On January 20, 2026, at 12:05 p.m. Resident R3's room was observed and Resident R3's father was interviewed due to the resident sleeping. During the interview the surveyor observed a plastic medication cup with several pills on a tray table that was over the bed for resident R3. When Resident R3's father was asked about the medication he stated the nurse left them for the resident to take when he woke up because he did not want to wake Resident R3 due to being in a deep sleep. The Director of Nursing Employee E3 was called to the room at 12:10 p.m. and confirmed at 12:14p.m. that two medications for the resident's medications were left by the licensed Nurse Employee E19 in a plastic medication cup on the resident's tray table for the resident. Interview held with the Director of Nursing on January 22, 2025, at 12:55 p.m. confirmed the licensed nurse Employee E19 is an agency staff and did leave the medications bedside for the resident to take once he woke up. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

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

Resident R3's medications at the bedside were immediately removed from the resident's room. Agency Nurse E19 was re-educated on Medication Administration Policy, and a Medication Administration competency was performed.
The DON or designee will re-educate licensed nurses on Medication Administration Policy with a focus on Medications to be administered at the time they are prepared and ensuring medications are not left at the bedside.
The DON or designee will conduct 5 random weekly observations of medication pass to ensure no medications are left at bedside x 12 weeks.
The DON of designee to review the results of these audits at the monthly QAPI meeting x 3 months

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations: Based on interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one Dialysis-Residents reviewed (Residents R9). Review of Resident 9's clinical records indicated that R9 was admitted in the facility on May 10, 2025, with Diagnoses including Dependence on Renal Dialysis (refers to the mandatory, long-term use of artificial filtration (hemodialysis or peritoneal dialysis) to replace lost kidney function). Review of physician order for R9, dated June 2, 2025, August 28, 2025, and January 16, 2026, revealed; Dialysis days: Tuesdays, Thursdays, and Saturdays. Time for Pick up: 5;30 a.m. Review of Resident R9 's Hemodialysis Communication Record revealed that it lacked the following information as required per the communication log: The portion on the Hemodialysis Communication Record marked "to be completed by Center Licensed Nurse for Dialysis patient prior to hemodialysis treatment", on August 14, 2025; September 20, 2025; October 11, 2025; October 28, 2025; and November 6, 2025. The portion on the Hemodialysis Communication Record marked "to be completed by Certified Dialysis Facility following Dialysis treatment and accompany patient on return to Center post-hemodialysis", on January 20, 2026. The portion on the Hemodialysis Communication Record marked "to be completed by Center Licensed Nurse post-hemodialysis treatment", on June 5, 2025; June 7, 2025; June 10, 2025; June 12, 2025; June 21, 2025; June 26, 2025; July 1, 2025; July 8, 2025; July 10, 2025; July 12, 2025; July 15, 2025; July 24, 2025; July 26, 2025; August 8, 2025; August 12, 2025; August 14, 2025; August 23, 2025; August 28, 2025; August 30, 2025; September 9, 2025; September 19, 2025; September 20, 2025; October 9, 2025; October 11, 2025; October 18, 2025; October 25, 2025; and October 28, 2025. Interview with the Charge Nurse, a Licensed Nurse, Employee E17, on January 23, 2026, at 11:22 a.m., confirmed lack of information in the Hemodialysis Communication Record of R9. 28 Pa Code 211.5(f) Clinical records

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

Resident R48 has been discharged from the facility.
Initial audit will be conducted by the DON or designee of current dialysis patients for the last 7 days to ensure communication records have been completed.
The Director of Nursing or designee will educate licensed nursing staff on the Dialysis policy, with the focus on ensuring communication forms between the facility and the dialysis center are complete.
The Director of Nursing or designee to conduct random audits of dialysis communication forms weekly x 12 weeks to verify documentation pre/post dialysis is complete.
The Director of Nursing or designee to review the results of these audits at the monthly QAPI meeting x 3 months.

§ 201.19(1) LICENSURE Personnel policies and procedures.:

(1) The employee's job description, educational background and employment history.

Observations: Based on a review of personnel files and interviews with facility staff in was determined that the facility failed to conduct background checks as required for one personnel file reviewed (Employee E21). Findings Include: Review of the facility policy titled, "Abuse Prohibition" revised November 14, 2025 states, "Policy-Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter "patient") property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms." Further review states, "3. The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. (Refer to Human Resources Policies and Procedures, Background Investigations policy." Review of Employee E21 file revealed the employee was hired on September 30, 2025. The facility failed to conduct a criminal background check within one year of the employee's date of hire. The date of the criminal background check given was September 17, 2024. An interview was held on January 22, 2025, at 12:30 p.m. with the Nursing Home Administrator Employee E1 confirmed that the criminal background check for Employee E21 had not been completed within a year of the date of hire. 28 Pa. Code 201.19Personnel policies and procedures.

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

The facility conducted a criminal background check for Employee 21.
The Administrator or designee will conduct an initial audit of new hires in the past 30 days to verify that a criminal background check has been performed.
The Administrator or designee will re-educate administration on ensuring new hires have a criminal background check within one year of the employee's date of hire.
The Administrator or designee will perform weekly audits of new hires to ensure a criminal background check has been completed within one year of the employee's date of hire.
The results of these audits will be reviewed during the monthly QAPI meeting x 3 months

§ 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.

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

All residents received care in accordance with their plan of care and attending physician orders
The Clinical Leadership Team and scheduler review the schedule daily. In the event of call-offs, the facility follows staffing policies, including exhausting all possible replacements from the internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.
All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted.
To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks, then monthly for two months.
Results will be taken to the QAPI for review and revision as needed.

§ 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.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement