Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Normandie Ridge during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and MSSA in the lungs was placed on droplet precautions, but a housekeeper failed to follow required infection control protocols, including improper removal of PPE, lack of hand hygiene, and not sanitizing equipment after use, contrary to facility policy and posted instructions.
A resident with complex cardiac conditions developed a pressure ulcer that was not assessed or documented by a Registered Nurse for nine days after initial identification by an LPN. During this period, the wound tracking form was not initiated, and no reassessment occurred after the resident's hospital transfer and return, resulting in delayed wound assessment and documentation.
The facility failed to ensure accurate MDS assessments for five residents, leading to discrepancies in clinical records. Errors included incorrect documentation of medical devices, diagnoses, and medications, confirmed by facility staff as coding inaccuracies.
The facility failed to update care plans for three residents, leading to deficiencies. A resident with a pacemaker lacked safety interventions in her care plan. Another resident's care plan incorrectly stated DNR status despite her wish for full treatment. A third resident's care plan did not reflect a reclassified stage 3 pressure ulcer and lacked pacemaker safety measures. The NHA acknowledged these issues.
A resident with specific care needs related to obesity and a urinary tract infection experienced delays in receiving assistance due to insufficient staffing. The facility's records showed prolonged call bell response times and failure to meet required nurse aide hours and ratios, as confirmed by the NHA and DON.
A facility failed to limit PRN psychotropic medications to 14 days or document rationale for extension for a resident with anxiety and depression. Another resident with Alzheimer's and hypothyroidism was not properly monitored for side effects of psychotropic medications, as evidenced by inaccurate documentation in the TARs. These deficiencies were acknowledged by the NHA and DON.
The facility failed to meet food safety standards, with undated and improperly stored food items, unsanitary food handling practices, and inadequate temperature control in kitchenettes. Observations revealed unlabeled food, moldy produce, and improper glove use, risking cross-contamination. Temperature logs showed repeated high readings without corrective actions.
A facility failed to include a focus area for antipsychotic medication use in a resident's care plan, despite the resident having an active order for Haloperidol to manage terminal agitation. The oversight was identified during a review of the resident's clinical records and confirmed by the Nursing Home Administrator.
A resident with hypertension and chronic atrial fibrillation did not receive consistent wound care for pressure ulcers as ordered. The Treatment Administration Record showed missed treatments for wounds on the mid and right back, with no progress notes explaining the omissions. The Nursing Home Administrator and DON expected documentation of completed treatments and notes if care was refused, leading to a deficiency in nursing services.
The facility failed to provide adaptive feeding devices for two residents. One resident, with atrial fibrillation and GERD, did not receive the required dycem under her plate, causing difficulty during meals. Another resident, with Parkinson's disease, was not given the prescribed Kennedy cup, instead receiving a sippy cup. Staff confirmed the unavailability of the required equipment.
Failure to Follow Droplet Precaution Protocols and Infection Control Policy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident on droplet precautions due to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and a diagnosis of methicillin susceptible Staphylococcus aureus (MSSA) in the lungs. Physician orders required droplet precautions with a respirator, all care and treatments to be completed in the room, and specific instructions for PPE use and hand hygiene. Facility policy also required handwashing before entering and after exiting the resident's room, and sanitizing reusable equipment. During observation, a housekeeper entered and exited the resident's room multiple times wearing a gown, gloves, face mask, and face shield, but failed to remove the face shield and mask prior to exiting the room as required. The housekeeper also did not perform hand hygiene after removing PPE and did not sanitize the mop handle used in the resident's room. These actions were inconsistent with both the facility's infection control policy and the posted droplet precaution instructions.
Failure to Timely Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and services consistent with professional standards to promote healing and prevent worsening of a pressure injury for a resident with significant medical conditions, including acute congestive heart failure and atrial flutter. Upon re-admission from a hospital stay, the resident's sacral area was documented as having intact, dry skin. However, an open area was identified on the left upper buttocks several days later, with documentation by an LPN noting the wound's size and characteristics. Despite this, there was no documented wound assessment or progress note completed by a Registered Nurse at the time of discovery, and the electronic wound assessment tracking form was not initiated until nine days after the wound was first identified. During this nine-day period, the resident was also transferred to and returned from the hospital, but no reassessment of the skin was documented upon return. The first comprehensive wound assessment was completed by a Registered Nurse only after this delay, at which point the wound had increased in size. Staff interviews confirmed the lack of documented wound assessments during this period, and the facility was unable to provide further information regarding the resident's wound care during the gap in documentation.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for five residents, leading to discrepancies in their clinical records and MDS documentation. Resident 20's MDS inaccurately indicated the presence of an indwelling catheter, which was not supported by clinical records. The Nursing Home Administrator confirmed this was a coding error. Resident 27's MDS assessments repeatedly failed to reflect accurate diagnoses, such as heart failure, depression, and the presence of a diabetic ulcer, despite the resident receiving medications for these conditions. The Director of Nursing confirmed these errors, acknowledging that the MDS should accurately represent the resident's status. Resident 29's MDS incorrectly documented the administration of anticoagulant medication, which was not supported by the Medication Administration Record. Similarly, Resident 49's MDS inaccurately indicated dialysis treatment, and Resident 56's MDS failed to reflect diagnoses of anxiety and depression, despite being prescribed related medications. These errors were confirmed by facility staff as coding inaccuracies.
Care Plan Deficiencies for Residents with Pacemakers and Inconsistent Code Status
Penalty
Summary
The facility failed to review and revise the care plans for three residents, leading to deficiencies in their care. Resident 19, diagnosed with atrial fibrillation and congestive heart failure, had a pacemaker but lacked safety interventions in her care plan. Despite having orders to ensure her pacemaker transmitter was operational every shift, the care plan did not address safety measures related to the pacemaker's presence. The Nursing Home Administrator (NHA) acknowledged the need for these safety measures but initially relied on staff's professional judgment. Resident 20's care plan was inconsistent with her wishes and physician orders. Although her POLST form indicated she wished to receive CPR and full treatment, her care plan incorrectly stated she was a DNR. This discrepancy was later confirmed by the NHA. Resident 27, with type 2 diabetes and a stage 3 pressure ulcer, had a care plan that failed to address the reclassification of her diabetic ulcer to a stage 3 pressure ulcer. Additionally, her care plan did not include safety interventions for her implanted pacemaker, similar to Resident 19. The NHA confirmed the need for revisions in Resident 27's care plan to reflect these changes.
Staffing Deficiency Leads to Resident's Unmet Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, specifically impacting one resident who was reviewed. This resident had diagnoses including obesity and a urinary tract infection, and their care plan required limited assistance for toileting and ambulation due to impaired balance and fatigue. Despite these needs, the resident reported waiting extended periods for staff assistance, resulting in an incident where they soiled themselves while waiting for their call bell to be answered. The facility's Device Activity Report confirmed multiple instances where the resident's call bell went unanswered for significant durations, ranging from approximately 26 to 51 minutes. Additionally, staffing records indicated that on a specific day, the facility did not meet the required nurse aide hours and ratios based on the census, which was confirmed by the Nursing Home Administrator and Director of Nursing. This deficiency in staffing directly contributed to the resident's unmet needs and compromised their well-being.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days or had documented rationale and duration for continuation beyond this period for one resident. Specifically, a resident with diagnoses of anxiety and depression had a PRN order for Lorazepam without a stop date, which was not accompanied by a documented rationale for extending the medication beyond 14 days, contrary to the facility's policy. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged the expectation for physicians to adhere to the policy. Additionally, the facility did not adequately monitor the effects and side effects of psychotropic medications for another resident diagnosed with Alzheimer's disease and hypothyroidism. The resident had multiple active orders for psychotropic medications, including Haloperidol and Lorazepam, with specific instructions to observe and document any side effects. However, the Treatment Administration Records (TARs) for several months showed only check marks, failing to accurately reflect whether the resident exhibited any side effects. There were no nurses' progress notes indicating the resident's response to the medications, and this documentation error was acknowledged by the Nursing Home Administrator and the Director of Nursing.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen and kitchenettes, as evidenced by multiple observations and interviews. During a tour of the kitchen, it was found that several food items in the walk-in production cooler and freezer were not dated or sealed properly, contrary to the facility's policy on labeling and dating. Additionally, the dry storage room contained opened packages without open dates, and the produce cooler had strawberries with visible mold, indicating a lack of proper monitoring and rotation of food items. Dented cans were also found on the canned goods rack, which should have been discarded upon receipt. In the Tulip kitchenette, improper food handling practices were observed. An employee was seen using the same pair of gloves to handle food and touch various surfaces, including a refrigerator door handle, without changing gloves in between tasks. This practice poses a risk of cross-contamination. Furthermore, the ice machine had a scoop stored inside, and an employee was observed retrieving ice without washing their hands, which is against sanitary protocols. The storage of utensils and dishes was also improper, with service sides facing upwards, increasing the risk of contamination. The facility's refrigerator temperature logs for the Tulip dining room kitchenette revealed several instances where temperatures exceeded the recommended 40 degrees Fahrenheit, with inadequate corrective actions documented. Despite the facility's policy requiring corrective actions when temperatures are out of range, the logs showed repeated high temperatures without appropriate follow-up. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that they expected proper labeling, dating, and storage of food, as well as adherence to sanitary serving practices, which were not met in these instances.
Failure to Implement Comprehensive Care Plan for Antipsychotic Use
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as Resident 56, which resulted in a deficiency. The facility's policy on care plans, last revised in March 2022, mandates that care plans should describe the services necessary to maintain a resident's highest practicable physical, mental, and psychosocial well-being. Resident 56's clinical record indicated diagnoses of Alzheimer's disease and hypothyroidism, and an active physician's order for Haloperidol to manage terminal agitation. However, the resident's care plan did not include a focus area or intervention for the use of this antipsychotic medication, which was a required component of their care plan. This oversight was identified during a review of the resident's clinical records and confirmed in an interview with the Nursing Home Administrator.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with pressure ulcers, as required by professional standards of practice. The resident, who had diagnoses including hypertension and chronic atrial fibrillation, had specific treatment orders for wounds on the mid and right back. The treatment for the mid back wound involved cleansing with normal saline, applying skin prep, medi honey, and securing with foam dressing daily. The treatment for the right back wound involved cleansing, applying skin prep, xeroform, and securing with a dry sterile dressing every two days. However, the Treatment Administration Record (TAR) for July 2024 showed that the mid back wound treatment was not completed on three occasions, and the right back wound treatment was not completed on two occasions. There were no progress notes in the resident's clinical record explaining why the wound treatments were not completed on the specified days. An interview with the Nursing Home Administrator and the Director of Nursing revealed that they expected staff to document completed treatments on the TAR and to write a progress note if the resident refused care. This lack of documentation and failure to provide consistent wound care led to the deficiency, as it did not align with the expected nursing services standards outlined in 28 Pa. Code 211.12(d)(1)(3)(5).
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for two residents, leading to deficiencies in their care. Resident 19, who has diagnoses including atrial fibrillation and GERD, had a care plan that required the use of dycem under her plate during meals to assist with her self-care performance deficit. However, during an observation, it was noted that Resident 19 did not have dycem under her plate, causing her plate to slide and requiring her to reposition it multiple times while eating. The dietary staff was initially unable to provide the dycem, and it was only given to her after a delay. Similarly, Resident 27, diagnosed with Parkinson's disease and muscle weakness, had a physician's order for a Kennedy cup to assist with nutrition and hydration. Despite this, observations revealed that Resident 27 was consistently provided with a two-handled sippy cup with a straw instead of the prescribed Kennedy cup. Staff interviews confirmed the unavailability of the Kennedy cup, which was reportedly stored elsewhere. The Nursing Home Administrator and Director of Nursing acknowledged the expectation that residents should receive their adaptive equipment as ordered.
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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.
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Nursing homes near York
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Margaret E. Moul Home | 0 mi | ★★★★★ | 4 | 0 |
| York North Skilled Nursing And Rehabilitation Ctr | 0.7 mi | ★★★★★ | 11 | 0 |
| Concordia At Spiritrust Sprenkle Drive | 1.9 mi | ★★★★★ | 1 | 0 |
| Yorkview Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 8 | 0 |
| Rest Haven-york | 3.4 mi | ★★★★★ | 8 | 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 July 2026) and official state health department websites.