Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Onyx Wellness Center during CMS and state inspections, most recent first.
A resident who was status post kidney transplant did not receive Tacrolimus after admission because the admitting nurse entered orders without a verified discharge med list and missed the medication in the hospital packet. The resident reported repeated requests for the anti-rejection med, and staff interviews confirmed the omission. The MAR lacked Tacrolimus, and later labs showed a critically low Tacrolimus level with abnormal renal function values.
A resident with COPD, hemiplegia, cerebral infarction, and severe cognitive impairment fell out of bed while trying to reach a snack bin that staff had placed next to and under the bed. Staff later found the resident on the floor with the legs in the snack bin and head lacerations requiring ED evaluation, two sutures, and multiple steri-strips.
Advance directive and POLST orders were not followed for two residents. One resident had a POLST for DNR/DNI/DNH and comfort measures only, but after an acute decline the guardian gave a verbal request to change code status to full code without proper documentation or a physician-signed update, and the resident was sent to the hospital. Another resident with severe cognitive impairment had a POLST for DNR/DNI/DNH and comfort measures only, but after being found on the floor with a head hematoma, an agency nurse called 911 and sent the resident to the ER without following the POLST or obtaining an order.
A resident admitted with dementia, bipolar disorder, cerebral ischemia, COPD, and difficulty walking did not have a baseline care plan developed within 48 hours for dementia care. The care plan addressed psychotropic medication effects, respiratory status, COPD, and fall risk, but the DON confirmed no dementia care interventions were in place.
Residents were left unsupervised in the dining area during meals, contrary to facility dining policy requiring staff to monitor residents, assist with meal service, and respond to resident needs. Six residents were observed without assigned supervision, and one resident made choking/grunting noises before an LPN intervened. A CNA stated she did not know she was scheduled to monitor the dining area, and the DON confirmed residents should never be left unattended while eating.
Food Storage and Labeling Deficiencies: Surveyors observed multiple food items in the kitchen without required date labels, including condiments, prepared chicken, applesauce, sliced apples, and Jell-O, with some items left uncovered. A container of jelly was past the facility’s storage limit, and scoops were left inside rice and flour bins in dry storage. The FSD acknowledged the items were not properly dated or covered per policy.
The NHA and DON failed to manage admission medication reconciliation for a resident with ESRD and a kidney transplant history who was ordered Tacrolimus 1.5 mg PO q12h. No Tacrolimus order was entered on admission, and the resident missed eight doses, with a critically low Tacrolimus level documented on lab review. The report states this contributed to an Immediate Jeopardy situation.
Surveyors found that the ice machine's inner lining was stained, the adjacent baseboard was peeling and dirty, and the floor around the machine had significant dirt and debris buildup, with several fruit flies present. These conditions demonstrated a failure to maintain essential kitchen equipment in a clean and sanitary manner.
Staff posted signs in resident rooms and dining areas that publicly displayed sensitive dietary and medical information, such as NPO and thickened liquid requirements, for multiple residents. Residents were also served meals on plastic trays in the dining areas, and interviews confirmed these practices, resulting in a failure to maintain resident dignity.
Surveyors found multiple deficiencies including unclean resident rooms with peeling tiles, broken furniture, and caked dirt, as well as a non-functioning hand sanitizer in the dining area. Additionally, agency staff were unfamiliar with residents and their diets, leading to inconsistent support during meal service.
A resident with advanced cognitive decline and COPD had a physician order for DNR, DNH, and DNI, but the POLST form incorrectly indicated CPR/Attempt Resuscitation. The DON confirmed the POLST did not match the physician's order, resulting in a deficiency for failing to ensure accurate documentation of code status.
A resident with diabetes, heart failure, and hypertension experienced ongoing foot problems, including an ingrown toenail and ruptured blisters. Despite repeated physician orders and nursing notes indicating the need for an urgent podiatry consult, the facility did not document timely arrangement of the consult. The resident was only assessed by podiatry when the specialist was later present in the building, as confirmed by the DON.
Agency nursing staff, including two nurses and a nurse aide, worked without receiving facility-specific training or competency evaluations. Multiple residents and a family member reported inadequate care and lack of familiarity with care needs. The DON confirmed that no skills competency assessments were conducted for these agency staff.
A resident with a diagnosis of dementia did not have an individualized, person-centered care plan with measurable goals and interventions to address their dementia care needs. The DON confirmed the absence of a dementia-specific care plan during staff interview.
Surveyors found that required Department of Health contact information was not posted or accessible on either nursing floor. The only visible posting in the lobby had an outdated phone number, and the only other posting was in Spanish. Several residents reported not knowing where to find this information, and staff confirmed the postings were missing due to recent renovations.
A resident with anxiety disorder, bipolar disorder, PTSD, and spinal stenosis did not have a comprehensive care plan addressing their behavioral health and pain management needs. Despite documented mental health diagnoses, pain issues, and substance use, the care plan lacked specific interventions for anxiety, PTSD, grief, and pain. Staff confirmed that no person-centered interventions were implemented to meet the resident's medical, mental, and psychosocial needs.
A resident with severe cognitive impairment and mobility issues fell out of bed and sustained fractures due to inadequate supervision during incontinence care. The facility failed to provide the required two-plus person assistance for bed mobility, as outlined in the resident's care plan, resulting in actual harm.
The facility failed to maintain a safe and comfortable environment for residents due to unresolved maintenance issues. Problems such as malfunctioning toilets, beds, and call bells were reported but not addressed in a timely manner, affecting residents' safety and comfort. The Maintenance Director confirmed the delays in resolving these issues.
The facility failed to provide palatable and properly temperature-controlled food and drink to residents. A test tray evaluation showed milk served at 57 degrees, above the acceptable 41 degrees, and poorly prepared meals. Resident interviews revealed dissatisfaction with meal content, temperature, and adherence to dietary needs, with reports of missing items and inappropriate food for dietary restrictions.
A facility failed to accurately complete a resident assessment for a resident. The resident's quarterly MDS indicated a discharge to a hospital, but the physician discharge summary showed the resident was discharged home with family. This discrepancy was confirmed by the RN Assessment Coordinator, who acknowledged the MDS was coded inaccurately.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with Parkinson's Disease was not wearing prescribed hand splints due to the absence of a care plan. Another resident with a urinary catheter reported it had not been changed since admission, and no care plan was in place. Additionally, a resident receiving hospice care lacked a care plan for hospice services. The DON and NHA confirmed these deficiencies.
A resident with Parkinson's Disease was not provided with restorative nursing programs as required. Despite physician orders for bilateral upper extremity resting hand splints to be worn after breakfast and removed before lunch, the resident was observed multiple times without the splints. Staff interviews revealed a lack of awareness and training regarding the resident's care plan, leading to the deficiency.
The facility failed to employ a qualified Food Service Director (FSD), as the current FSD lacked necessary certifications and qualifications. Despite being responsible for food service operations, the FSD did not hold a Certified Dietary Manager (CDM) or Certified Food Manager (CFM) certification, nor did he have a relevant degree or receive regular consultations from a qualified dietitian. The Administrator confirmed the FSD's unqualified status during a review of his credentials.
Missed Tacrolimus Doses After Admission
Penalty
Summary
The facility failed to ensure a newly admitted resident who was status post kidney transplant received Tacrolimus, an immunosuppressive medication prescribed to prevent organ rejection. The resident had a history of ESRD, renal transplant, coronary artery disease, heart failure, hypertension, peripheral vascular disease, diabetes mellitus, acquired immunodeficiency, and bilateral below-knee amputations. The resident was cognitively intact and was admitted from an acute care hospital with an order for Tacrolimus 1.5 mg by mouth every 12 hours. After admission, the resident’s MAR did not contain an order for Tacrolimus, and the resident reported not receiving the anti-rejection medication since admission. The resident stated that staff did not seem to know anything about the medication and that the issue had been raised repeatedly without resolution. The resident also reported informing the ADON about the missed medication and remained concerned about missing this critical part of the medication regimen. Staff interviews showed the admitting nurse entered the resident’s medication orders without receiving the official hospital discharge summary containing a verified medication list. The nurse relied on a comprehensive packet of hospital records, acknowledged that Tacrolimus was listed in the packet, and stated, "I must have missed that one." She also reported she did not independently verify the medication list with the hospital. The physician was later notified that the resident had missed doses of Tacrolimus, and laboratory testing showed a Tacrolimus level below the therapeutic range along with abnormal renal function values. The report states the resident missed a total of eight doses of Tacrolimus.
Resident Fell From Bed While Reaching for Accessible Snack Bin
Penalty
Summary
The facility failed to ensure that Resident R87’s snack bin was not placed in a location easily accessible to the resident. Resident R87 was admitted with diagnoses including COPD, hemiplegia affecting the right dominant side, and cerebral infarction, and had a BIMS score of 3, indicating severe cognitive impairment. The resident’s care plan identified a risk for falls or fall-related injury and included an intervention, initiated July 2, 2025, directing staff to remove the snack bin out of the resident’s sight and reach. Despite that intervention, the snack bin was kept next to the resident’s bed and later under the bed by the headboard. On July 1, 2025, staff observed the resident lying inside the snack box while reaching for snacks. On February 7, 2026, staff found the resident on the floor with the legs in the snack bin and three lacerations to the head. The facility investigation stated that at about 5:00 a.m. the resident was given food and drink from the snack bin at the resident’s request, and at about 6:30 a.m. the resident attempted to lean over in bed to get another snack from the bin, rolled off the bed, and sustained head lacerations requiring emergency department evaluation, two sutures, and multiple steri-strips.
Advance Directive and POLST Orders Not Followed
Penalty
Summary
The facility failed to ensure that residents’ advance directives and POLST orders were followed according to their expressed wishes for 2 of 2 residents reviewed with advance directives. The facility policy stated that residents must be informed of their right to accept or refuse treatment, create an advance directive, and have any advance directive maintained in the medical record. The policy also addressed POLST forms as medical orders that must reflect the patient’s treatment preferences and be reviewed and updated when the patient’s condition changes. For one resident, the record showed a POLST signed by the resident, physician, and RN indicating DNR, DNI, DNH, and comfort measures only, with no artificial hydration or nutrition by tube. The resident had been in the facility since 2021, had moderate cognitive impairment, and diagnoses including CVA, diabetes mellitus, and hyperlipidemia. During an acute decline with fever, respiratory distress, elevated blood pressure, tachycardia, hypernatremia, and chest X-ray findings suggestive of pneumonia, the resident’s representative was notified of the resident’s condition and interventions. On January 8, 2026, Social Services notified the DON that the guardian had changed the code status to full code, and the resident was sent to the hospital. The social worker stated she acted on the guardian’s verbal instruction without obtaining proper documentation, verifying authority, or ensuring a physician-signed POLST update, and she could not locate a second POLST form that she believed existed. For the second resident, the record showed admission with heart failure, protein-calorie malnutrition, and cerebral infarct, with severe cognitive impairment on MDS. The resident’s POLST, signed by the resident and representative, indicated DNR, DNI, DNH, and comfort measures only. After the resident was found on the floor with a hematoma to the head and nose area, an agency nurse called 911 and sent the resident to the ER without following the POLST and without obtaining an order for transfer. The facility investigation stated the agency nurse did not follow the resident’s POLST for DNR/DNI/DNH, and the DON confirmed that the POLST was not followed.
Baseline Care Plan Not Developed for Dementia Care
Penalty
Summary
The facility did not ensure a baseline care plan was developed within 48 hours of admission for Resident R9 related to dementia care. Resident R9 was admitted with diagnoses including dementia, bipolar disorder, cerebral ischemia, COPD, and difficulty walking. Review of the clinical record showed a care plan dated January 15, 2026 that addressed potential discomfort or side effects from psychotropic medications, altered respiratory status, COPD, and fall risk, but it did not include interventions for the resident’s dementia care needs. The Director of Nursing confirmed on March 5, 2026 that no care plan was in place related to Resident R9’s dementia care needs.
Residents Left Unsupervised During Meals
Penalty
Summary
The facility failed to ensure that residents were provided appropriate supervision while dining for 6 of 6 residents observed, including R60, R92, R58, R94, R101, and R39. Facility policy titled Dining Service requires residents to receive a nourishing, balanced diet served in accordance with their preferences, with staff responsible for validating meal accuracy, assisting with meal service, monitoring residents during meals, and responding to resident needs; it also states trays must not be left unattended and residents must have adequate time and support to safely complete meals. On March 5, 2026, at 08:35, the six residents were observed in the first-floor dining area without assigned supervision, and one resident made choking/grunting noises. An LPN intervened after noticing the resident and stated that residents should not be left alone. A CNA who came into the room stated she was unaware she was scheduled to monitor the dining area. The DON later confirmed that facility protocol requires nursing staff to monitor residents during all meals and that residents should never be left unattended while eating.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices on four of its four nursing units. During review of the Nutrition Services Practice Manual, the facility’s food storage policies required perishable foods to be refrigerated at proper temperatures, raw meats to be stored separately from vegetables and cooked foods, all products to be labeled with the delivery date, leftovers to be stored in shallow containers and labeled with the recipe name and date of storage, refrigerator leftovers to be discarded after 72 hours, and pre-dish items to be covered to prevent drying and cross-contamination. During the initial kitchen tour, surveyors observed multiple food storage items without required date labeling, including sour cream, salsa, coleslaw dressing, relish, PAM cooking spray, diced chicken prepared for chicken salad, applesauce, sliced apples, and three trays of Jell-O that were uncovered. A container of jelly was dated February 21 and exceeded the facility’s seven-day storage guideline. In the dry storage area, rice and flour bins had scoops left inside the bins. The Food Service Director acknowledged that several food items were not properly dated or covered in accordance with facility policy.
Failure to Ensure Critical Immunosuppressant Medication on Admission
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure that a newly admitted resident with End-Stage Renal Disease and a kidney transplant history received a life-sustaining medication. The resident was admitted with an order to continue Tacrolimus 1.5 mg by mouth every 12 hours, a critical immunosuppressant needed to prevent organ rejection. Review of the Medication Administration Record showed that no Tacrolimus order was entered on admission, and the resident did not receive the medication from February 27 through March 3, 2026, missing eight doses. Facility policies required nursing staff to obtain a complete medication history, reconcile medications with hospital discharge summaries, prior MARs, and physician orders, and ensure critical medications were administered promptly. The resident’s laboratory results on March 3, 2026 showed a critically low Tacrolimus level of less than 2.0 ng/mL, below the therapeutic range. The report states that the NHA and DON failed to ensure the essential functions and duties of their positions, contributing to an Immediate Jeopardy situation.
Unsanitary Conditions Observed in Kitchen Ice Machine Area
Penalty
Summary
During a tour of the main kitchen with the Food Service Director, surveyors observed that the facility failed to maintain essential kitchen equipment in a clean and sanitary condition. Specifically, the inner lining of the ice machine had a blackish/brown stain along the bottom half perimeter. Additionally, the plastic baseboard adjacent to the ice machine was peeling off and had a significant build-up of dirt and debris. The floor underneath and surrounding the ice machine was also dirty, with a substantial accumulation of dirt and debris, and several fruit flies were seen hovering in the area. These findings indicate that the facility did not adhere to professional standards for the storage, preparation, and distribution of food as required.
Failure to Protect Resident Dignity Through Public Posting of Medical Information
Penalty
Summary
The facility failed to maintain and enhance resident dignity on both the first and second floor nursing units. During observations, a sign listing nine residents' dietary restrictions, including NPO (nothing by mouth), thickened liquid requirements, and other specific instructions, was posted at the head of a resident's bed, making private medical information visible. Additionally, in both the first and second floor dining areas, signs indicating thickened liquid diets were publicly posted on the wall. Residents were observed being served meals on plastic trays in the dining rooms. Interviews with residents and staff confirmed the presence of these postings and the use of plastic trays for meal service. These actions resulted in the public display of sensitive resident information and did not promote an environment that supports the dignity of each resident.
Failure to Maintain Clean, Homelike Environment and Consistent Staff Support
Penalty
Summary
Surveyors observed multiple deficiencies related to the maintenance of a safe, clean, and homelike environment across both nursing units. Specific findings included a wall with red paint markings, peeling baseboards, a bathroom leak with a saturated towel on the floor, and a broken glove box that could not hold gloves. Additional issues included a broken closet drawer, air conditioning vents with heavy dust accumulation, and a non-functioning hand sanitizer dispenser in the dining room. In another room, several bathroom floor tiles were peeling, and there was visible residue from dried tube feeding formula and caked dirt under and around the bed, as well as on a fall mat. During meal service observations, staff issues were also noted. One resident reported that an aide refused to pass out meal trays, stating she was agency staff and unfamiliar with residents' names. Another aide admitted to not knowing all the residents in the dining area. These findings indicate that the facility did not ensure a clean, well-maintained environment or a consistent, knowledgeable staff presence during resident dining experiences.
Inaccurate POLST Form Fails to Reflect Resident's Code Status
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's Physician Orders for Life Sustaining Treatment (POLST) form accurately reflected the resident's code status as documented in the physician's order. The resident, who had diagnoses of senile degeneration of the brain and chronic obstructive pulmonary disease, was admitted with specific physician orders indicating Do Not Resuscitate (DNR), Do Not Hospitalize (DNH), and Do Not Intubate (DNI) status. However, upon review, the POLST form for this resident was found to indicate CPR/Attempt Resuscitation, which was inconsistent with the physician's documented orders in the electronic medical record. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the POLST form did not match the resident's code status as ordered by the physician. The failure to ensure consistency between the physician's orders and the POLST form constituted a violation of resident care policies and nursing services regulations.
Failure to Timely Arrange Podiatry Consult for Resident with Foot Issues
Penalty
Summary
A deficiency was identified when the facility failed to timely arrange a podiatry appointment for a resident with significant risk factors, including congestive heart failure, type 2 diabetes mellitus, and hypertension. The resident's care plan included an intervention to consult podiatry as ordered. Multiple nursing and medication administration notes documented the need for an urgent podiatry consult due to an ingrown toenail and subsequent physician orders, but there was no documented evidence that the consult was arranged in a timely manner as required. The resident continued to experience foot issues, including pain and ruptured blisters, and only received a podiatry assessment when the podiatrist was present in the facility at a later date. The Director of Nursing confirmed that there was no documentation showing that the podiatry consult was ordered as per physician instructions. This failure was found to be noncompliant with resident care policies and nursing services regulations.
Failure to Ensure Agency Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that agency nursing staff, including two licensed nurses and one nurse aide, demonstrated the necessary competencies and skill sets to meet residents' needs. Multiple residents reported that agency staff did not provide adequate care, with specific complaints that agency staff did not assist them, did not give showers at night, and were not attentive to their needs. A family member also stated that agency staff were unfamiliar with residents' care requirements and did not appropriately reapproach residents who declined care. Review of facility staffing schedules confirmed that the agency staff in question worked on the specified date. Observations showed that both agency nurses administered medications on their first day at the facility without having received any training or skills competency evaluations from the facility. Personnel file reviews for all three agency staff revealed no documentation of training or competency assessments. The Director of Nursing confirmed that no skills competency evaluations had been conducted for these agency staff members.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the dementia care needs of a resident diagnosed with dementia. Clinical record review showed that the resident was admitted with a diagnosis of dementia, but the interdisciplinary plan of care did not include measurable goals or interventions specific to dementia care. During an interview, the DON confirmed that the care plan lacked this information and no additional documentation was provided to address the resident's dementia-related needs. This deficiency was identified for one of 32 residents reviewed, based on both clinical record review and staff interview.
Failure to Post Required Department of Health Contact Information
Penalty
Summary
The facility failed to ensure that the required Department of Health contact information was posted and readily accessible on both nursing floors. During observations, it was found that there were no postings for the Department of Health contact information on the first floor nursing unit, and the only posting in the lobby area contained an outdated phone number. On the second floor, the only visible posting was in Spanish, with no English version available. Clear plastic coverings intended for these notices were empty on both floors. The Director of Social Services confirmed the absence of the required postings and explained that one resident sometimes removed the paper, but at the time of the survey, no current postings were present. Resident interviews during a council meeting revealed that several residents were unaware of where to find information on how to contact the State Department of Health within the building. The Nursing Home Administrator confirmed that the postings had been removed during recent bathroom renovations and had not been replaced. The lack of accessible and accurate postings for the Department of Health contact information was observed and confirmed by both staff and residents.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Behavioral Health and Medical Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the behavioral health and medical needs of a resident diagnosed with anxiety disorder, bipolar disorder, PTSD, and spinal stenosis. Despite multiple clinical assessments and documentation by the physician's assistant and psychologist noting the resident's mental health diagnoses, pain issues, and recent trauma from the loss of a family member, there were no care plan interventions created or revised to address these specific needs. The resident was prescribed medications for anxiety, depression, and pain, but the care plan did not reflect interventions for managing anxiety related to outside stressors, PTSD, grief, or paranoid and anxious behaviors. Further review revealed that the resident experienced episodes of lethargy, unsteadiness, and was found to have used marijuana via a vape pen, which was against facility policy. The resident's medications for anxiety and pain were held due to concerns about the effects of combining them with marijuana use. Despite the psychologist discussing relaxation techniques with the resident, there was no documentation of what these techniques were or their inclusion in the care plan. Interviews with staff confirmed that no person-centered care plan interventions were implemented to address the resident's medical, mental, and psychosocial needs.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
Towne Manor West was found to be non-compliant with federal and state regulations due to a failure in providing adequate supervision during incontinence care for a resident, resulting in actual harm. The facility's policy required assistance from more than one staff member for residents needing two-plus person physical assistance for bed mobility. However, during an incident, a single staff member attempted to provide care, leading to the resident falling out of bed and sustaining fractures to the left arm and hip. The resident, who had severe cognitive impairment and required significant assistance for bed mobility, was not adequately supervised according to their care plan. The resident involved had a history of chronic obstructive pulmonary disease, lack of coordination, abnormalities of gait and mobility, and dementia. The incident occurred when a nurse aide, while providing care, asked the resident to roll over, resulting in the resident falling from the bed. The facility's documentation and staff interviews confirmed that the resident required two-plus person assistance for bed mobility, which was not provided at the time of the incident. This lack of adherence to the care plan and facility policy led to the resident's injuries, highlighting a significant lapse in supervision and care.
Plan Of Correction
All residents have the potential to be affected by this deficient practice. 1) The Director of Nursing (DON) immediately updated the care plan of the resident with 2 assists for turning and repositioning. 2) The Facility educator and/or designee will in-service all the nurses, Minimum Data Set (MDS) Coordinator, and Certified Nursing Assistants (CNA) on Federal Guidelines F 689 related incident and accidents. 3) The Facility Educator and/or designee will in-service all the nurses and Certified Nursing Assistants (CNA) on accuracy of documentation in the Point of Care Service (POC) task. 4) The DON and/or designee will in-service the MDS Coordinator on accuracy of MDS assessment and documentation of CNA in the POC. 5) The DON and/or designee will audit 5 residents' ADL care plan to ensure that resident's bed mobility/turning and repositioning are documented according to the Point of Care Task/Kardex weekly x 4 weeks and monthly x 3 months. The DON will submit the audit reports to the Quality Assurance Committee.
Facility Fails to Address Maintenance Issues Promptly
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for nine residents, as evidenced by multiple unresolved maintenance issues. The facility's policy, "Environment of Care," requires that work orders be prioritized and addressed in a timely manner, but this was not adhered to. Several work orders, including those for malfunctioning toilets, beds, and call bells, were left open and unresolved for extended periods, impacting the residents' ability to receive care and services safely. Resident R1 and R2 experienced issues with a non-flushing and overflowing toilet in their room, which was reported on November 16, 2024, but remained unresolved as of December 9, 2024. Resident R1 also reported a malfunctioning bed that was not addressed promptly, leading to a room change. Similarly, Resident R9 had a mattress issue reported on December 3, 2024, which was only resolved six days later. Residents R7 and R8 had a non-functioning call bell, and they were only provided with hand-held bells on the day of the survey. Additional unresolved issues included a leaking ceiling in Resident R5's room, reported on September 16, 2024, and a broken call light in the room of Residents R3 and R4, reported on November 15, 2024. The Maintenance Director confirmed that these work orders were not addressed in a timely manner, indicating a systemic failure in the facility's maintenance processes, which compromised the residents' safety and comfort.
Plan Of Correction
1. The toilets in room 128 and in the 2nd floor north side shower room have been repaired. Rooms 018 and 024 call bell has been repaired. Missing ceiling tile in room 003 has been replaced. 2. Maintenance director/designee will audit all current open work order requests to ensure they are addressed timely. 3. Administrator/designee will reeducate Maintenance director on ensuring work order requests are addressed timely. 4. Maintenance director/designee will conduct audits of all new work order request to ensure timely completion, weekly X4 monthly X 3. Finding will be presented to QAPI Quarterly X 2.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at the proper temperature for all 18 residents interviewed. A test tray evaluation conducted during a lunch meal revealed that the milk was served at 57 degrees, which is above the acceptable standard of 41 degrees. Additionally, the baked ziti was not properly baked, the noodles were overcooked, and the meat sauce had an off sweet flavor. The mixed vegetables were also overcooked, with the squash being so soft that it could not be picked up with a fork. These findings were confirmed by the Food Service Director. Resident interviews revealed widespread dissatisfaction with the food service. Residents reported not receiving items listed on their meal tickets, such as breakfast meats and coffee, and expressed concerns about the nutritional content of their meals, particularly for those with dietary restrictions like diabetes or lactose intolerance. Some residents reported receiving food items they should avoid, such as pork and dairy, while others noted that the food was often too spicy or had too much gravy. A group meeting with alert and oriented residents further confirmed dissatisfaction with the taste and temperature of the food, describing it as dry, overcooked, and unappetizing.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to accurately complete a resident assessment for one of the residents reviewed, identified as Resident R102. A review of Resident R102's quarterly Minimum Data Set (MDS), which is an assessment of resident needs, dated May 15, 2024, indicated that the resident was discharged to a hospital. However, a review of the resident's physician discharge summary revealed that the resident was actually discharged home with family. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator, Employee E8, on August 1, 2024, who acknowledged that Resident R102's MDS was coded inaccurately.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident R56, diagnosed with Parkinson's Disease, had an order for bilateral upper extremity resting hand splints to be worn after breakfast and removed before lunch. However, observations revealed that the resident was not wearing the splints, and there was no care plan in place for their use. The Director of Nursing confirmed the absence of a care plan for the hand splints, despite the physician's order. Resident R97, admitted with Fournier's gangrene, had a urinary catheter with orders for daily care and drainage every shift. The resident reported that the catheter had not been changed since admission, and there was no care plan for its use and care. Similarly, Resident R71, who was receiving hospice care for end-stage senile dementia, did not have a care plan developed for hospice services. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the lack of care plans for these residents, which is against the facility's expectations.
Failure to Provide Restorative Nursing Programs for Resident with Parkinson's Disease
Penalty
Summary
The facility failed to provide restorative nursing programs for a resident diagnosed with Parkinson's Disease, which affects the nervous system and causes difficulty in movement. The resident was admitted with impairments in both upper extremities, as noted in the Minimum Data Set assessment. Observations revealed that the resident's hands and wrists were flexed and contracted, and she was not wearing her prescribed bilateral upper extremity resting hand splints. These splints were ordered to be worn after breakfast and removed before lunch daily, but they were consistently found on the nightstand instead of being worn by the resident. Interviews with staff, including a nurse aide and the Director of Nursing, confirmed that the resident was not wearing the hand splints as ordered. The nurse aide was unaware of the requirement to place the hand splints on the resident, as it was not part of her usual assignment. Additionally, another CNA, who worked a different shift, was also unaware of the order despite it being noted on the resident's care card. The Director of Nursing acknowledged the oversight and mentioned that the facility was in the process of training CNA staff to perform these restorative nursing orders.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as evidenced by the findings from staff interviews and a review of employee credentials. Employee E4, the Food Service Director (FSD), was responsible for overseeing the ordering, receiving, storing, preparation, and service of food. However, during an interview, the FSD confirmed that he did not hold a certification as a Certified Dietary Manager (CDM) or Certified Food Manager (CFM), nor did he have a national certification for food service management and safety from a national certifying body. Additionally, he lacked an associate's or higher degree in food service management or hospitality from an accredited institution and had not received regularly scheduled consultations from a qualified dietitian. A review of Employee E4's credentials further revealed that he did not meet the statutory qualifications required for the position. During a subsequent interview with the Administrator, it was confirmed that the FSD had not completed the necessary program or taken the exam for the required certifications. The Administrator was unable to provide evidence of the FSD's certification, confirming his unqualified status to direct the dietary department.
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 1,761 citations issued within 25 miles in the last 12 months — including the 14 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 Norristown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ivory Wellness Center | 0.2 mi | ★★★★★ | 15 | 0 |
| Norriton Square Nursing And Rehabilitation Center | 0.4 mi | ★★★★★ | 16 | 0 |
| Markley Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 21 | 0 |
| Suburban Woods Health & Reha | 0.9 mi | ★★★★★ | 10 | 0 |
| Aristacare At Meadow Springs | 1.7 mi | ★★★★★ | 21 | 2 |
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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.