Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brinton Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was admitted with an unstageable sacral pressure ulcer previously managed with a wound VAC and regular dressing changes. On admission, staff documented the presence and stage of the sacral ulcer but did not record required details such as wound measurements, slough percentage, or exudate, as required by facility policy. The hospital-initiated wound VAC treatment was not continued, and although a physician later ordered NSS cleansing and medical honey with dry dressings every shift, the TAR showed no sacral wound treatment was documented until two days after admission. A subsequent wound consult documented a large unstageable sacral wound with significant slough and undermining, and the DON confirmed the wound was not comprehensively assessed or treated until that consult date.
The facility failed to follow physician orders for two residents regarding the administration of Midodrine HCL. One resident with dialysis-induced hypotension and CHF received the medication outside prescribed parameters 24 times, while another resident with hypotension and acute respiratory failure received it outside parameters 13 times. The DON confirmed these errors.
A resident developed an unstageable wound on the left heel, and the facility failed to meet professional standards by not properly assessing, documenting, or identifying the person responsible for applying an undated dressing. The DON confirmed that the dressing was kept in a locked treatment cart accessible only to nurses, and the staff should have assessed the wound and notified the physician.
A resident with diabetes and peripheral vascular disease developed an unstageable pressure ulcer on the left heel due to the facility's failure to assess, monitor, and treat the skin impairment. The ulcer, covered with 80% slough, required surgical debridement. The dressing was not dated, and the responsible nurse was not identified, despite only nurses having access to the treatment supplies.
The facility failed to meet the required staffing levels for nurse aides, with insufficient coverage on multiple shifts. Specifically, the day shift lacked adequate staffing on two occasions, the evening shift on one occasion, and the night shift on nine occasions. These deficiencies were identified through a review of staffing data and communicated to the Nursing Home Administrator.
A resident with multiple chronic conditions, including diabetes and legal blindness, was mistakenly given a roommate's medications by an orientee who misidentified the resident during medication pass. The error was discovered after the medications, including Gabapentin, Baclofen, and Vistaril, were administered, but the resident showed no adverse effects.
The facility did not meet the required nurse aide staffing ratios during specific shifts between December 16 and December 25, 2024. The day shift was understaffed on three occasions, the evening shift once, and the night shift three times. These deficiencies were confirmed through staffing data and a discussion with the Nursing Home Administrator.
A facility failed to maintain a sanitary environment for a resident, as a black substance was observed around the sink faucet in the resident's room. The substance was easily removable, indicating a lack of proper cleaning. This issue was noted during a survey and discussed with the NHA.
The facility failed to properly store and label medications in two medication carts and one medication room. Observations showed multiple insulin vials and pens were opened and undated, with some lacking labels. Additionally, the medication room's refrigerator was not functioning properly, with a thermometer and medications embedded in frozen water, and the temperature had not been recorded for several days. These deficiencies were confirmed by staff and reported to the DON.
The facility did not complete a criminal background check for a newly hired nurse aide in accordance with its policy, which requires such checks to be completed before employment. The background check for the nurse aide, hired in February, was not obtained until May, as confirmed by the Nursing Home Administrator.
A facility failed to maintain or restore bladder continence for a resident who was initially continent but later occasionally incontinent. The resident was identified as a candidate for scheduled toileting, yet no care plan was in place, and there was no evidence of scheduled toileting being offered. These findings were presented to the facility's administration.
A resident experienced a significant weight gain of 19.3 lbs over 10 days, but the facility failed to obtain a timely reweight as per policy. Despite a dietitian's request for a reweight due to the gain, the next weight was recorded 13 days later, which was confirmed by the dietitian.
A facility failed to ensure accurate pain management for a resident receiving scheduled Oxycodone. Despite the resident's claims of pain, the eMAR showed the medication was administered 58 times for a reported pain level of 0. A nurse admitted to inaccurately recording the pain level, and the administration confirmed the need for accurate documentation.
A resident with Obstructive Sleep Apnea and Acute Respiratory Failure went nearly two weeks without a CPAP machine, despite physician orders. Conflicting documentation and interviews with the DON and NHA failed to clarify the discrepancy.
Failure to Timely Assess and Treat Unstageable Sacral Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and timely treat an unstageable sacral pressure ulcer for one resident. The facility’s pressure ulcer policy required staff to examine the skin of new admissions and document a full pressure sore assessment, including location, stage, measurements (length, width, depth), exudate, and necrotic tissue. Hospital records dated December 28, 2025, showed the resident was admitted with an unstageable sacral wound that had been treated with a wound VAC and dressing changes three times weekly. On admission, the facility’s skin assessment documented an unstageable sacral pressure ulcer but did not include wound measurements, the presence or percentage of slough, or the presence of exudate, contrary to facility policy. Further record review showed that the wound VAC treatment ordered at the hospital was not initiated upon admission, as there was no evidence of a wound VAC order on the January 2026 TAR. A physician’s progress note dated January 6, 2026, indicated the wound VAC was being held due to a large amount of slough, and a new order was written to cleanse the sacral wound with NSS, apply medical honey, and cover with a dry dressing every shift. However, the TAR showed that no sacral wound treatment was documented until January 7, 2026, two days after the unstageable sacral ulcer was identified on admission. A wound consult on January 7, 2026, documented the sacral wound as unstageable, measuring 6.8 x 7.7 x 1.0 cm with 60% slough and undermining from 6 to 7 o’clock. In an interview, the DON confirmed that the resident’s unstageable sacral wound was not comprehensively assessed until the wound physician visit on January 7, 2026, and that there was no documented evidence of wound treatment before that date.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of medications for two residents, identified as R3 and R33. Resident R3, who has a diagnosis of dialysis-induced hypotension and congestive heart failure, was prescribed Midodrine HCL to manage low blood pressure, with specific instructions to hold the medication if blood pressure exceeded 120/70. However, a review of the medication administration record for December 2025 revealed that the medication was administered outside of these parameters 24 times. Similarly, Resident R33, diagnosed with hypotension and acute respiratory failure with hypoxia, was also prescribed Midodrine HCL with instructions to hold the medication if systolic blood pressure was greater than 120 or diastolic blood pressure was greater than 80. The medication administration record for March 2025 showed that the medication was administered outside of these parameters 13 times. An interview with the Director of Nursing confirmed these medication errors, indicating a failure by the facility to ensure that the medication orders for Residents R3 and R33 were followed correctly.
Plan Of Correction
1. Resident R3 no longer resides in the facility. R33 continues on Midodrine. Physician orders/parameters followed as ordered. 2. Current residents on Midodrine have been reviewed by DON or designee to ensure Midodrine physician orders followed as ordered. 3. Licensed staff will be educated by the DON or designee on Midodrine parameters. 4. Random audits of residents on Midodrine will be completed by DON or Designee weekly x4 to ensure medication is administered per physician orders.
Failure to Properly Assess and Document Skin Impairment
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident identified as Resident 39, who developed a skin impairment. According to the Pennsylvania Professional Nursing Practice Act, nurses are required to exercise sound nursing judgment and participate in the planning, implementing, and evaluating of nursing care. The facility's policy on pressure ulcers mandates that nursing staff assess and document significant risk factors for pressure sores, including a full assessment of any pressure sore. However, a review of Resident 39's care plan and nursing progress notes revealed that an unstageable wound was discovered on the resident's left heel, with a dressing applied that was not dated or initialed, indicating a lack of proper documentation and assessment. The facility's investigation into the incident revealed that the wound dressing was applied without proper documentation, and the person responsible for applying it could not be identified. Interviews with staff, including a licensed nurse and the Director of Nursing (DON), confirmed that the dressing was kept in a locked treatment cart accessible only to nurses. The DON acknowledged that upon identifying the skin impairment, the staff should have assessed the wound, notified the physician, and provided appropriate monitoring and treatment. This deficiency was previously cited in past surveys, indicating a recurring issue with nursing services and clinical record maintenance.
Plan Of Correction
1. Resident R39 wound dressing is dated and physician orders for the wound treatment are being followed. 2. Current residents with wound dressings have been reviewed by the DON or designee to ensure treatments are dated and physician orders for the treatment are in place. 3. Licensed staff will be educated by the DON or designee on wound treatment dressings which cannot be applied on a skin impairment without physician orders. If a skin impairment is identified, the physician will be notified and wound treatment orders will be obtained. 4. Random audits of residents with wound dressings will be completed by the DON or designee weekly x4 to ensure wound dressings are dated and physician orders are followed. The audits will be reported to QAPI committee and the QAPI committee will determine the need for further audits.
Failure to Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly assess, monitor, and treat a skin impairment for a resident, leading to a deficiency in care. The resident, who had a history of diabetes and peripheral vascular disease, was found to have an unstageable pressure ulcer on the left heel during wound rounds. The facility's policy required timely assessment and documentation of pressure sores, but the resident's clinical record did not reflect any skin impairments aside from an existing issue on the right hip until the wound team discovered the new ulcer. The nursing progress notes and facility investigation revealed that the dressing on the resident's left heel was not dated or initialed, making it unclear how long it had been in place. The wound nurse practitioner noted that the ulcer was covered with 80% slough and required surgical debridement. The facility's investigation could not determine who applied the dressing, but it was noted that only nurses had access to the treatment cart where the dressing supplies were kept. Interviews with staff, including the Director of Nursing, confirmed that the resident's left foot was already compromised due to medical conditions and a right leg amputation. The Director of Nursing acknowledged that the wound should have been assessed and treated promptly. The failure to do so resulted in the development of an advanced unstageable pressure ulcer, necessitating surgical intervention.
Plan Of Correction
1. Resident R39 wound dressing is dated and physician orders for the wound treatment are being followed. 2. Current residents with wound dressings have been reviewed by the DON or designee to ensure treatments are dated and physician orders for the treatment are in place. 3. Licensed staff will be educated by the DON or designee on wound treatment dressings which cannot be applied on a skin impairment without physician orders. If a skin impairment is identified, the physician will be notified and wound treatment orders will be obtained. 4. Random audits of residents with wound dressings will be completed by the DON or designee weekly x4 to ensure wound dressings are dated and physician orders are followed. The audits will be reported to QAPI committee and the QAPI committee will determine the need for further audits.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain a minimum of one nurse aide per 10 residents during the day shift on March 21 and March 30, 2025. Additionally, the evening shift on March 29, 2025, did not have the required one nurse aide per 11 residents. Furthermore, the night shift was understaffed on nine occasions between March 21 and March 30, 2025, failing to provide one nurse aide per 15 residents. These deficiencies were identified through a review of the facility's staffing data and were communicated to the Nursing Home Administrator during a telephone interview on April 7, 2025.
Plan Of Correction
1. Nurse Aide staffing ratios will be reviewed for last 7 days to evaluate if nurse aide ratios were met. 2. Administration and scheduler will continue to contact the multiple agencies under contract and in house staff to fill callouts and meet ratios. All resources to meet staffing regulations will be utilized. 3. Nursing administration and scheduler will be reeducated on nurse staffing and ratio requirements. 4. Audits of nurse aide ratios will be conducted weekly x4 weeks by NHA/Designee to ensure nurse aide ratio is met. Audits will be reported to QAPI for review and further recommendations as needed.
Medication Administration Error Due to Staff Misidentification
Penalty
Summary
A medication administration error occurred when a staff member, while orienting a new employee, instructed the orientee to administer medications to a resident. The orientee entered the room, called out another resident's name, and upon receiving a response from the wrong resident, proceeded to administer medications intended for the roommate. The error was realized after the orientee confirmed with the resident at the door bed, and the supervising staff recognized that the medications had been given to the incorrect individual. The resident who received the wrong medications had a medical history including a cochlear implant, hypothyroidism, hyperlipidemia, type 2 diabetes mellitus, and legal blindness. The medications administered in error included Gabapentin, Baclofen, and Vistaril, which were not prescribed for this resident. Clinical records indicated that the resident did not experience any changes in mental or functional status following the incident.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a period from December 16 through December 25, 2024. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on December 16, 19, and 21. Additionally, the evening shift on December 23 did not meet the requirement of one nurse aide per 11 residents. Furthermore, the night shift on December 20, 21, and 23 fell short of the required one nurse aide per 15 residents. These deficiencies were confirmed through a review of the facility's staffing data and corroborated by the Nursing Home Administrator during a telephone interview on January 3, 2025.
Plan Of Correction
1. Nurse Aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios were met. 2. Administration and scheduler will continue to contact the multiple agencies under contract and in-house staff to fill callouts and meet ratios. All resources to meet staffing regulations will be utilized. 3. Nursing administration and scheduler will be reeducated on nurse staffing and ratio requirements. 4. Audits of nurse aide ratios will be conducted weekly x4 weeks by NHA/Designee to ensure nurse aide ratio is met. Audits will be reported to QAPI for review and further recommendations as needed.
Failure to Maintain Sanitary Environment in Resident's Room
Penalty
Summary
The facility failed to provide a safe and sanitary environment for a resident, as observed during a survey. On October 8, 2024, at 9:45 a.m., a black substance was noted surrounding the faucet fixture in the resident's room. This issue persisted until 11:30 a.m. when the Nursing Home Administrator was present, and it was observed that the substance could be easily removed with a paper towel. The deficiency was discussed with the Nursing Home Administrator on the same day, highlighting the facility's failure to maintain a clean and safe environment for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in two medication carts and one medication room. Observations revealed multiple instances of insulin vials and pens being opened and undated, with some lacking labels entirely. Specifically, Medication Cart B contained undated vials and pens of Lispro, Lantus, Aspart, Levemir, and Humalog insulins. Employee E3 confirmed the insulins should have been dated upon opening and was unsure why they were not labeled with residents' names. Similarly, Medication Cart A had undated vials and pens of Aspart and Lispro insulins, along with medication cups containing green tablets and yellow capsules, identified as Iron pills and Omega 3, respectively, due to space constraints in the drawer. In Medication Room A, the refrigerator door was found not closing properly, with the top tray area covered in frozen water, embedding a thermometer, a bag of normal saline, and two insulin pens. The bottom tray contained unopened insulin vials and pens, and the refrigerator's temperature had not been recorded since September 25, 2024. These observations were made in the presence of the Director of Nursing, who was informed of the findings. The facility's failure to adhere to proper medication storage and labeling protocols was noted as a deficiency.
Failure to Conduct Timely Background Check for New Hire
Penalty
Summary
The facility failed to adhere to its policy regarding the completion of criminal background checks for new hires. Specifically, the policy mandates that background checks, including criminal conviction checks, be initiated within two days of an employment offer and completed before the employee begins work. However, for nurse aide Employee E4, who was hired on February 23, 2024, the criminal background check was not obtained until May 8, 2024. This oversight was confirmed during an interview with the Nursing Home Administrator on May 9, 2024. The failure to conduct a timely background check is a violation of the facility's policy and relevant state codes concerning the responsibility of the licensee, management, and resident rights.
Failure to Provide Scheduled Toileting for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or restore bladder continence for a resident. The resident was initially assessed as always continent of bladder, but later assessments indicated occasional incontinence. Despite being identified as a candidate for scheduled toileting or timed voiding, there was no plan of care addressing the resident's incontinence, nor evidence that scheduled toileting or timed voiding was offered. These findings were presented to the Nursing Home Administrator and Director of Nursing.
Failure to Timely Monitor Resident's Weight Change
Penalty
Summary
The facility failed to monitor weight changes in a timely manner for a resident, identified as Resident 62, who was reviewed for nutrition. According to the facility's policy, any weight change of 5% or more since the last weight assessment should be retaken the next day for confirmation. Resident 62 experienced a significant weight gain of 19.3 pounds, or 10.72%, over a 10-day period from November 25, 2023, to December 5, 2023. A dietitian noted this weight change on December 6, 2023, and requested a reweight due to the 19-pound gain over two weeks, with no noted fluid retention and intake trending over 75%. However, the next weight was not obtained until December 18, 2023, which was 13 days after the initial weight change recording and 12 days following the dietitian's request for a reweight. This delay was confirmed by the dietitian during an interview on May 9, 2024.
Inaccurate Pain Management Documentation
Penalty
Summary
The facility failed to provide the highest practicable pain management for a resident, identified as Resident 20, who was on a scheduled pain medication regimen. According to the Minimum Data Set (MDS) assessment dated April 19, 2024, Resident 20 was receiving scheduled pain medication. The clinical record showed an active order for Oxycodone 10 mg, to be administered three times a day for severe pain rated 8-10. However, the electronic medication administration record (eMAR) for April 2024 indicated that the medication was administered 58 times for a reported pain level of 0 out of 10. During an interview, a registered nurse (Employee E1) admitted to recording a pain level of 0, despite the resident's claims of experiencing pain. The Nursing Home Administration confirmed that the nurse should have accurately recorded the resident's pain severity before administering the medication.
Failure to Provide CPAP Machine as Ordered
Penalty
Summary
The facility failed to follow physician orders for medication treatments for a resident diagnosed with Obstructive Sleep Apnea and Acute Respiratory Failure with Hypoxia. The resident, admitted on December 8, 2023, went nearly two weeks without a CPAP machine, which is essential for proper breathing. A progress note dated December 14, 2023, indicated the need for a new CPAP machine due to a malfunction. However, subsequent progress notes from December 15, 2023, to December 21, 2023, indicated that the resident did not receive the CPAP machine during this period. Despite this, the medication administration record for December 2023 showed that the resident was receiving CPAP treatments on days when the equipment was documented as unavailable. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed conflicting information. The DON stated that the resident never went without a CPAP machine and that the progress notes referred to a new CPAP machine for home use, despite the resident having no discharge plan. The DON and NHA could not explain the conflicting documentation regarding the timely receipt of the new CPAP machine.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Glen Mills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Maris Grove | 1.4 mi | ★★★★★ | 6 | 0 |
| Willowbrooke Court-granite | 3.5 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court Skd Care Center At Lima Estates | 3.6 mi | ★★★★★ | 0 | 0 |
| Fair Acres Geriatric Center | 3.6 mi | ★★★★★ | 17 | 0 |
| Hcc At White Horse Village | 4.6 mi | ★★★★★ | 3 | 0 |
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