Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Two residents were inaccurately assessed on MDS documentation. One resident was documented as having an indwelling foley catheter despite no physician orders, no care plan interventions, and the resident denying ever needing one; the DON confirmed the MDS was wrong. Another resident with diabetic retinopathy and documented visual impairment stated he/she could only see shadows, yet the MDS indicated adequate vision in adequate light, and the DON confirmed the assessment was incorrect.
Failure to Follow Fluid Restriction and Fall Mat Orders: The facility did not follow fluid restriction orders for three residents with CHF and CKD-related conditions, as fluid intake was not monitored or documented and water, coffee, soda, and Ensure were found at the bedside despite ordered limits. Residents stated they did not know how much fluid they were allowed, and the DON confirmed the fluid restrictions were not appropriately followed. The facility also failed to place a fall mat on the ordered window side of another resident’s bed, with staff confirming the mat was on the wrong side.
The facility failed to provide sanitary handling and storage of nebulizer equipment for one resident, with the mask, cup, and tubing left on a bedside table, unlabeled, and containing clear liquid. The facility also failed to follow another resident’s respiratory orders: O2 was observed at 4–5 L/min instead of the ordered 2 L/min via NC, and the resident’s ordered AVAP at bedtime was not followed, with a CPAP machine in use instead. The DON confirmed the order discrepancies.
The facility failed to document appropriate indications before giving a resident PRN Lorazepam and did not document behavior or psychotropic side effect monitoring for a resident receiving Olanzapine. The resident had bipolar disorder and anxiety disorder, and the DON confirmed the PRN medication was given without appropriate indications and that monitoring was not done.
PASARR Level II Services Not Incorporated Into Care Plan: A resident with anxiety disorder, bipolar disorder, and schizophrenia was completely dependent on staff for ADLs and required substantial assistance with mobility. The facility did not identify the resident’s PASARR Level II status on the MDS, and although the care plan noted PASARR II criteria and an MCO contact, it did not specify the specialized services or their frequency. The MCO service plan called for weekly specialized services, but staff could not describe them and the record contained no documentation of the services.
A physician failed to document a rationale when disagreeing with pharmacist medication review recommendations for three residents. The reviews addressed a Voltaren gel order, long-term Protonix use for GERD, and routine loratadine use, but the physician marked disagree without explaining the decision, and the related order changes were not made.
Failure to Provide Ordered Therapy Services: A resident with TBI, MS, muscle wasting/atrophy, and generalized weakness was certified for PT with good rehab potential, but therapy was only provided for four sessions before it stopped. Staff could not produce a discharge summary or document why the resident was discharged or why there was an 11-day gap in services without notification. The resident reported therapy had started and then stopped without explanation.
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.
Inaccurate MDS Assessments for Foley Catheter and Vision Status
Penalty
Summary
The facility failed to properly assess two residents in the clinical record and MDS documentation. For Resident 3, the quarterly MDS dated April 22, 2026 indicated in Section H0100 that the resident had an indwelling foley catheter, but there were no current, discharged, or completed physician orders for a foley catheter in the record and no care plan or interventions addressing one. During interview on June 3, 2026, Resident 3 denied ever requiring an indwelling foley catheter, and the DON later confirmed that Resident 3 did not require one and that the MDS was inaccurately documented. For Resident 66, the medical record showed a diagnosis of diabetic retinopathy and a care plan focus dated April 14, 2025 for impaired visual function related to DM with bilateral diabetic retinopathy. During interview on June 2, 2026, Resident 66 stated that he/she had a visual deficit and was only able to see shadows. However, the May 7, 2026 quarterly MDS, Section B1000, indicated the resident had adequate ability to see in adequate light. When this was reviewed with the DON on June 4, 2026, the DON confirmed Resident 66 had a visual deficit and that the MDS was incorrectly documented.
Failure to Follow Fluid Restriction and Fall Mat Orders
Penalty
Summary
The facility failed to appropriately monitor and follow fluid restriction orders for Residents 1, 7, and 37. Resident 1 had diagnoses of chronic congestive heart failure and hepatic failure, and a physician order for a 2000 ml daily fluid restriction divided across meals and nursing shifts. Review of the resident’s May and June 2026 MAR showed the total fluid intake each shift was not monitored or documented. During observation, a 16-ounce cup of water was found on the bedside table, and the resident stated staff provided and refilled the water cup and that residents did not know how much fluid they were allowed to take each meal or shift. Resident 7 had diagnoses of CHF and chronic kidney disease and a physician order for a 1500 ml daily fluid restriction divided across meals and nursing shifts. The resident’s May and June 2026 MAR showed the total fluid intake each shift was not monitored or documented, and the resident also received Ensure Plus twice daily without documentation of the amount consumed. During observation, a cup of water and an extra cup of coffee were found at the bedside. The resident stated staff provided and refilled the water cup and that the resident knew about the fluid restriction but did not know how much fluid was allowed each shift or meal. The DON confirmed the cup of water should not have been placed in the room and that the resident’s fluid intake was not appropriately monitored and followed. Resident 37 had chronic diastolic congestive heart failure and a physician order for a 2000 ml daily fluid restriction divided across meals and nursing shifts. The May and June 2026 eMAR showed the resident’s total fluid intake each shift was not monitored or documented, and there was no documentation identifying the amount of fluid provided. Observations showed multiple cups of water and a Coca-Cola bottle on the resident’s tray/table. The resident was unable to state the amounts of fluids permitted per meal or shift, and both an LNE and the DON confirmed the resident was on a fluid restriction and should not have had soda or multiple cups of water at the bedside. The facility also failed to follow Resident 53’s fall mat order. The resident had a history of falling, and the physician order and care plan directed that a fall mat be placed on the window side of the bed with checks every shift. Observations on multiple days showed the fall mat placed on the left side of the bed and no mat on the right, window side. An LNE and the RN confirmed the mat was placed on the left side rather than as ordered.
Failure to Follow Respiratory Orders and Maintain Nebulizer Equipment
Penalty
Summary
The facility failed to provide sanitary handling, cleaning, and storage of nebulizer equipment for one resident. On June 4 and June 5, 2026, a nebulizer mask, medicine cup, and tubing were observed on the resident’s bedside table among other belongings, with the tubing unlabeled and a small amount of clear liquid remaining in the medication cup. The facility policy for administering medications through a small volume nebulizer required rinsing and disinfecting the equipment according to protocol, washing the pieces in warm soapy water, allowing them to air dry on a paper towel, and storing the equipment in a plastic bag with the resident’s name and date when completely dry. The facility also failed to follow respiratory orders for another resident with acute and chronic respiratory failure with hypoxia and chronic respiratory failure with hypercapnia. The resident had an active order for oxygen at 2 L/min continuously via nasal cannula for COPD, with a baseline O2 saturation of 90%, but observations on June 2 and June 3, 2026, showed the oxygen concentrator set at 4–5 L/min. In addition, the resident had an order to use their own AVAP at bedtime, but observations on June 2, June 3, and June 4, 2026, showed a bedside machine labeled CPAP set at 6.0 cm H2O. The resident stated the home machine had broken a few weeks earlier and the facility provided the current machine being used, and the DON confirmed the oxygen was not set according to the physician’s order and that the AVAP order was not followed.
Failure to Document Indications and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor a resident's behaviors, medication side effects, and document indications for psychotropic medication use for one resident reviewed. Resident 13 had diagnoses of bipolar disorder and anxiety disorder and was ordered Olanzapine 20 mg at bedtime for bipolar disorder, along with Lorazepam 1 mg every 12 hours as needed for anxiety, with the order renewed every 14 days. A review of the May 2026 MAR showed Resident 13 received as-needed Lorazepam 41 times during the month without an appropriate indication documented. The record also did not document the resident's behaviors or psychotropic side effect monitoring. The DON confirmed in interview that the resident was administered as-needed Lorazepam without appropriate indications and that behavior and side effect monitoring for the antipsychotic medication was not done.
PASARR Level II Services Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to incorporate PASARR Level II recommendations into the care plan for one resident with significant behavioral health diagnoses. The resident’s annual MDS dated December 5, 2025 showed complete dependence on staff for activities of daily living and substantial assistance needed for mobility, with diagnoses including anxiety disorder, bipolar disorder, and schizophrenia. The resident was receiving antipsychotic, anti-platelet, hypoglycemic, and anti-seizure medications. The facility also failed to indicate on the MDS that the resident qualified for a Level II PASARR determination. Review of the resident’s PASARR dated June 25, 2019 showed that a further Level II evaluation was required. The facility care plan stated that the resident met PASARR II criteria secondary to serious mental illness and included an intervention to consult the MCO, but it did not specify the specialized services to be provided or how often they were to occur. The Person-Centered Service Plan from the MCO stated that the resident was to receive specialized services through the MCO weekly for 90 days between January 13, 2025, and June 16, 2026, totaling two times. An interview with Employee E4, with the DON present, revealed that the resident was to receive specialized services but the employee could not state what those services were, and the facility had no documentation of the services in the resident’s record.
Physician Did Not Document Rationale for Disagreeing With Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented a rationale when disagreeing with pharmacist-identified medication irregularities during monthly drug regimen reviews for three residents. For Resident 3, a June 2026 pharmacist review noted that Voltaren gel was ordered to be applied for 12 hours on and 12 hours off, and recommended removing those instructions because the gel can be applied up to four times daily. The physician signed the recommendation as disagreeing with it on the same date, but did not provide a rationale, and the physician orders showed the change was not made. For Resident 9, the physician order summary showed Protonix 40 mg daily for GERD, and a June 2026 medication reconciliation review noted long-term PPI use since 3/2023 with a recommendation to consider reducing the dose to 20 mg daily. The physician marked disagree without documenting a rationale. For Resident 18, pharmacist reviews in January 2026 and June 2026 noted routine loratadine use since December 2024 and recommended evaluating the current need and considering PRN use if appropriate. In both instances, the physician signed disagree without providing a rationale, and the physician orders showed the changes were not made.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for Resident 34. Resident 34’s annual MDS dated March 20, 2026, identified the resident as cognitively intact and dependent on facility staff for activities of daily living and mobility, with diagnoses including traumatic brain injury, multiple sclerosis, muscle wasting and atrophy, and generalized muscle weakness. The facility policy stated therapy services would be designed to help residents attain and maintain their highest practicable level of physical well-being. Resident 34 reported that therapy had evaluated them a couple of weeks earlier and had come to the room a couple of times, but then stopped and the resident did not know why. The physical therapy evaluation dated May 13, 2026, certified Resident 34 for 12 PT sessions within a 30-day period and documented good rehab potential. Treatment notes showed therapy was provided only on May 13, May 14, May 21, and May 23, 2026. The summary of daily skilled services for May 23, 2026, stated the resident actively participated and had no complexities or barriers impacting the session. E6 stated the resident had been discharged from therapy on June 3, 2026, but no discharge summary was in the chart. E7, with the DON and NHA present, confirmed the discharge date but could not provide the discharge summary and stated the resident could continue therapy by asking for it. The facility did not document why the resident was discharged after only four sessions or why there was an 11-day gap in therapy services without notification of discharge.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,354 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 7 | 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 | ★★★★★ | 19 | 1 |
| Hcc At White Horse Village | 4.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.