ONYX WELLNESS CENTER
For profit - Limited Liability company
119 Beds
PARAMOUNT CARE CENTERS
Data: November 2025
Trust Grade
25/100
#471 of 653 in PA
Photo by Onyx Nursing and Rehabilitation
Photo by Onyx Nursing and Rehabilitation
Photo by Onyx Nursing and Rehabilitation
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Families considering Onyx Wellness Center in Norristown, Pennsylvania should be aware that it has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #471 out of 653 facilities in Pennsylvania places it in the bottom half, and #45 out of 58 in Montgomery County suggests limited local options that perform better. The facility's trend is worsening, with issues increasing from 6 in 2024 to 10 in 2025. While staffing is a strength with a rating of 4 out of 5 stars, turnover is concerning at 64%, which is higher than the state average. However, the facility has faced serious incidents, including a resident suffering fractures after being improperly assisted during care, and ongoing concerns about food safety and cleanliness, including dirty ice machines and food storage areas.
- Trust Score
- F
- In Pennsylvania
- #471/653
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 64% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $112,875 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 28%
Review needed
6 → 10 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 10 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 64%
18pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $112,875
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: PARAMOUNT CARE CENTERS
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (64%)
16 points above Pennsylvania average of 48%
The Ugly 24 deficiencies on record
1 actual harm
May 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure the POLST form accurately reflected the resident's code status for one of 32 residents reviewed (Resident R15).
Findings Include:
Review of Resident R15's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of Senile Degeneration of Brain ( a decline in an individual's memory, behavior, and cognitive abilities) and Chronic Obstructive Pulmonary Disease (a progressive lung disease characterized by difficulty breathing, often caused by long-term exposure to irritants).
Review of Resident R15's electronic medical record revealed a physician order dated [DATE], that specified the resident's code status was Do Not Resuscitate (DNR - allow natural death if resident found with no pulse and is not breathing), Do Not Hospitalize (DNH), and Do Not Intubate (DNI).
Further review of Resident R15's electronic medical record revealed a form, Physician Orders for Life Sustaining Treatment (POLST), dated and signed by the physician on February 14, 2019, that indicated the resident's code status was a CPR/Attempt Resuscitation (Cardiopulmonary Resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest).
Interview with the Director of Nursing , on [DATE], at 12:50 p.m., confirmed the POLST form did not accurately reflect the physician order for code status on Resident R15's electronic medical record.
28 Pa Code 211.10(d) Resident care policies.
28 Pa Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interview, it was determined that the facility failed to timely arrange a podiatry appointment for one of two residents reviewed for foot care (Resident R...
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Based on review of clinical records and staff interview, it was determined that the facility failed to timely arrange a podiatry appointment for one of two residents reviewed for foot care (Resident R47).
Findings Include:
Review of Resident R47's comprehensive care plan revised December 3, 2022, revealed the resident had potential for impaired skin integrity related to congestive heart failure (heart is not able to pump enough blood to meet the body's needs causing fluid build up in the body), type 2 diabetes mellitus (body's inability to effectively process sugars (glucose) causing high blood sugar levels), and hypertension (high blood pressure). Intervention dated January 5, 2025, included to consult podiatry as ordered.
Review of Resident R47's clinical record revealed a nursing note dated December 5, 2024, that indicated upon assessment with the wound team, Resident R47's right great toe was noted with ingrown toenail and touching second toe. Per the note, treatment was applied and podiatry aware and will follow-up.
Review of Resident R47's clinical record revealed medication administration note dated December 9, 2024, consult appointment needed with podiatry ASAP (as soon as possible) d/c (discontinue) when complete. Further review of the note revealed [Resident R47] needs consult for podiatry per MD for right foot greater and first toe.
Review of Resident R47's clinical record revealed medication administration note dated December 14, 2024, consult appointment needed with podiatry ASAP (as soon as possible) d/c (discontinued) when complete. Further review of the note revealed [Resident R47] needs consult for podiatry per MD (physician) for right foot greater and first toe.
Review of Resident R47's clinical record revealed medication administration note dated December 15, 2024, consult appointment needed with podiatry ASAP d/c when complete. Further review of the note revealed [Resident R47] needs consult for podiatry per MD for right foot greater and first toe.
Review of Resident R47's clinical record revealed medication administration note dated December 20, 2024, consult appointment needed with podiatry ASAP d/c when complete.
Review of Resident 47's entire clinical record revealed no documented evidence podiatry was consulted as ordered by the physician.
Further review of Resident R47's clinical record revealed a nursing note dated December 30, 2024, that the resident complained of feet pain and upon assessment by the nurse Resident R47 was noted with ruptured blisters to bilateral feet. Podiatry was in the building and consulted to assess the resident.
Interview on May 22, 2025, at 1:07 p.m. with the Director of Nursing, Employee E2, confirmed the facility did not have documented evidence that a podiatry consult was timely ordered per the physician orders.
28 Pa Code 211.10(d) Resident care policies.
28 Pa Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observations, review of facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that agency nursing sta...
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Based on observations, review of facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that agency nursing staff demonstrated competencies and skill sets necessary to care for residents' needs for three of three agency personnel files reviewed (Employees E9, E10 and E11).
Findings include:
Interview on May 20, 2025, at 10:35 a.m. Resident R89 stated, agency staff don't give good care.
Interview on May 20, 2025, at 11:02 a.m. Resident R27 stated, agency staff don't do anything for us.
Interview on May 20, 2025, at 12:36 p.m. Resident R37 stated, agency staff just sit around and don't give us care.
Interview on May 21, 2025, at 9:37 a.m. Resident R80 stated, agency staff don't give us care and never give showers at night.
Interview on May 21, 2025, at 11:14 a.m. Resident R44's family member stated, agency staff don't know residents' care needs and don't reapproach Resident R44 when she's having a tough day or declines care.
Review of facility staffing schedules revealed that Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide; worked at the facility on May 20, 2025, as agency nursing staff.
Observation on May 20, 2025, at 9:28 a.m. revealed Employee E9, agency licensed nurse, prepare and administer medications to Resident R103. Interview, at the time of the observation, Employee E9, agency licensed nurse, stated that it was her first day working at the facility and that she did not receive any trainings or skills competency evaluations by the facility.
Observation on May 20, 2025, at 11:00 a.m. revealed Employee E10, agency licensed nurse, prepare and administer medications to Resident R91. Interview, at the time of the observation, Employee E10, agency licensed nurse, also stated that it was her first day working at the facility and confirmed that she did not receive any trainings or skills competency evaluations by the facility.
Review of personnel files for Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide; revealed that there were no trainings or skills competency evaluations that were conducted by the facility available for review at the time of the survey.
Interview on May 22, 2025, at 11:46 a.m. the Director of Nursing confirmed that the facility did not conduct any skills competency evaluations for Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide.
28 Pa. Code 201.20(a)(b) Staff development
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an indi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 32 residents reviewed (Resident R 67).
Findings Include:
Review of the admission sheet of Resident 67, revealed that Resident R67 was admitted to the facility on [DATE], with diagnoses including Dementia (Dementia is a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
On May 21, 2025, at 1:55 p.m., review of Resident R67's interdisciplinary plan of care revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R67.
During an interview on May 21, 2025, at 2:05 p.m., the Director of Nursing (DON), confirmed the finding, and the DON stated that the facility tried to make the care plans as specific as possible. No additional information was received.
The facility overlooked to develop and implement a person-centered care plan to include and support Resident R67's dementia care needs.
28 Pa Code 211.11(d) Resident care plan
28 Pa Code 211.12 (d)(1)(3)(5) Nursing service
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observations and interviews with staff, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for two o...
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Based on observations and interviews with staff, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for two of two nursing units (First floor and Second floor nursing units).
Findings Include:
Observations during the initial tour on May 20, 2025 at 1:01 p.m. revealed Resident R92's room had a NPO (nothing per mouth) sign posted at the head on the resident's bed on the wall. The sign had nine residents information listed.
Four residents listed as NPO
Four residents listed as Necar Thick
One resident listed as Honey.
Two residents listed as No straws
Two residents listed as Do Not Leave Liquids at Bedside
Observations on May 20, 2025 at 12:34 p.m. of the first floor nursing units activities/dining room revealed residents were being served their meals on plastic trays. Further observation for dining area revealed a Thickened liquids sign posted in the dining area on the left when you walk in on the wall.
Interview with Resident R1 on April 1, 2025, at 11:30 a.m. stated facility always serves the food on the trays for meals.
Observations during a follow up day on May 22, 2025 at 11:53 a.m. on the second floor unit in the activities/dining room during lunch revealed residents were being served their meals on plastic trays. Further observation for dining area revealed a Thickened liquids sign posted in the dining area on the left when you walk in on the wall.
Interview with Regional Employee E3 on May 22, 2025 at 11:56 a.m. confirmed the Liquid Diet Posting was posted on the dining room wall area on the left when you walk in.
28 Pa. Code 201.29 (j) Resident Rights
28 Pa. Code 211.12 (d)(1) Nursing Services
28 Pa. Code 211.12 (d)(5) Nursing Services
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, and staff interviews, it was determined that the facility did not ensure clean and h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, and staff interviews, it was determined that the facility did not ensure clean and homelike environment was maintained in resident care areas and dining experience for two of two nursing units observed (First Floor and Second Floor).
Findings Include:
Observations on May 20, 2025, at 10:20 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed a red paint colored on the wall next to the A-Bed.
Observations on May 20, 2025, at 10:40 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed the baseboard along the perimeter of the wall behind the B-bed was peeling off.
Observations on May 20, 2025, at 10:51 a.m. revealed the resident had a bathroom with a leak behind toilet, on the floor was a wet saturated towel between the sink and toilet area along the wall. On the wall in the bathroom there was also a broken piece of plastic from the plastic box that holds gloves. The box was broken so that no gloves could be held inside of it.
Observations on May 20, 2025, at 11:03 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed the bottom drawer on the right side of the closet was broken and hanging off.
Observations on May 20, 2025, at 11:08 a.m. revealed Resident R38's room revealed the air conditioning vents had heavy caked on dust.
Observations during the initial tour on May 20, 2025 at 12:34 p.m. of the first floor nursing units activities/dining room revealed residents were being served their meals in this room. There was one hand sanitizer located on the wall in the dining room which was not working at the time.
Observations on May 20, 2025 at 1:01 p.m. of Resident R92's room revealed the resident's bathroom had several floor tiles that were peeling. The resident was laying in her bed and at the head of the bed underneath the bed there was residue from dried up tube feeding formula and caked up dirt visible on the floor and on the baseboards. To the left of Resident R92's bed was one fall mat which also had dried up tube feeding formula.
Continued observations on May 22, 2025 at 11:53 a.m. on the second floor (upper floor) unit revealed Resident R80 came out to the nurses station and said that aide is sitting down in there and she said, I am not passing out trays because I am agency staff and I don't know anybodys names.
After entering the dining/activities room on the second floor nurse aide Employee E14 was seen getting up out of a chair with a cellphone in one hand a bag of chips in the other. Employee E14 was asked her name and stated it. When asked if it was her first time working at the facility Employee E14 stated, no it's not but I don't know these peoples names and diets and then walked out of the dining room area.
Nurse aide Employee E15 was also in the room in the same area as Employee E15 and started to attempt to open up to food truck and read to lunch meal tickets. Employee E15 was asked if she was familiar with the residents in the room and she stated, some of them.
28 Pa. Code 201.14 (a) Responsibility of licensee.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and staff interview it was determined that the facility failed to maintain essential kitchen equipment in clean and sanitary conditions related to the ice machine.
Findings Incl...
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Based on observations and staff interview it was determined that the facility failed to maintain essential kitchen equipment in clean and sanitary conditions related to the ice machine.
Findings Include:
A tour of the main kitchen was conducted on May 20, 2025, at 9:20 a.m. with Food Service Director, Employee E16.
Observations inside the ice machine revealed the white, plastic, inner lining had a blackish/brown stain along the bottom half perimeter.
Further observations of the area surrounding the ice machine revealed the plastic baseboard along the wall adjacent (facing) the ice machine was peeling off and has significant build-up of dirt and debris.
The floor underneath and surrounding the area of the ice machine was dirty and had a significant build up of dirt and debris. Three to four fruit flies were hovering the area of the ice machine.
28 Pa. Code 201.14 (a) Responsibility of licensee.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0574
(Tag F0574)
Minor procedural issue · This affected most or all residents
Based on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact informa...
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Based on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact information, readily accessible on two of two nursing floors. (1st Floor, 2nd Nursing Units)
Findings Include:
Review of facility policy titled, Resident Rights with a revision date of August 31, 2022 states, Purpose: Ensures residents know that they can lodge complaints without reprecussions.
During an observation of First Floor nursing units on May 20, 2025 at 11:00 a.m. revealed there was no posting for the required Department of Health contact information. A tour of the lobby area revealed there was a standard size page for the contact information for Department of Health but the phone number was outdated in between the exterior door of the lobby and the interior glass door of the lobby.
Resident Council meeting was held on May 22, 2025, at 10:30 a.m. on the first floor with nine awake, alert, and oriented residents. Several residents reported that they were not aware of where the information on how to contact the State Department of Health is in the building. (R50, R74, R78, R93).
A tour was taken with the Director of Social Services, Employee E12 Observation of the First Floor Nursing unit with the Employee E12 on May 22th at 1:05 p.m. to look for required notices and postings.
A tour of the first floor (bottom floor) nursing unit revealed there were no required Department of Health contact information posted. The Director of Social Services, Employee E12 showed the surveyor a clear plastic covering next to the elevator that did not have a paper in it and stated, it is usually here, but we have one resident and sometimes he takes the paper.
The tour of the second floor (top floor) revealed there was another clear plastic covering next to the elevator that did not have a paper in it. Further review of floor revealed there was one posted size posting for the Department of Health but it was written in Spanish. The Director of Social Services Employee E12 confirmed 2:03 p.m. that there were no postings for the required Department of Health contact information in English on either on the nursing units (first floor or second floor).
Interview with the Nursing Home Administrator Employee E1 on May 22, 2025 at 2:09 p.m. confirmed that there was no posting for the Department of Health contact information in English in the facility due to renovations of the bathrooms over the weekend and the signs had been taken down.
28 Pa. Code: 201.18(a)(e)(1) Management
28 Pa. Code: 201.18(b)(1) Management
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observations of care and services, interviews with residents and staff, review of clinical records and policy and procedures, it was determined that the facility failed to develop and impleme...
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Based on observations of care and services, interviews with residents and staff, review of clinical records and policy and procedures, it was determined that the facility failed to develop and implement a comprehensive care plan to meet the behavioral health and medical needs of one of seven residents reviewed with anxiety disorder, bipolar disorder, post traumatic stress disorder and spinal stenosis. ( Resident R1)
Findings include:
A review of the policy titled drug screening and drug searches for Residents dated February 24, 2025 revealed that it was the responsibility of the facility staff to maintain an environment for the residents that was free of medical marijuana on it's premises. The policy indicated that illicit drugs may include cannabis, hallucinogens opiates or amphetamines. The policy indicated that a resident found using drugs illegally would be referred to drug counseling.
Clinical record review revealed a comprehensive quarterly assessment MDS(an assessment of care needs) dated February 14, 2025 that indicated that Resident R1 was cognitively intact. The assessment also indicated that this resident had diagnoses of anxiety disorder, depression, manic depression (bipolar disease) and PTSD (post traumatic stress disorder).
Clinical record review revealed that Resident R1 had been identified by the PA (physician's assistant) on February 20, 2025 as being prescribed Zoloft (antidepressant) and Xanax (antianxiety agent) as needed for anxiety disorder. The PA also documented that this resident had spinal stenosis pain and was prescribed tramadol as needed for pain management. The PA indicated that this resident had bipolar disorder, major depression and post traumatic stress disorder.
Clinical record review indicated that the psychologist documented on February 24, 2025 that Resident R1 had anxiety disorder from outside stressors; however the stressors were not specifically documented. The psychologist mentioned that Resident R1 was experiencing trauma from the loss of her father to cancer. The psychologist indicated that this resident was paranoid, anxious and depressed. There was no care plan developed or revised to address anxiety with outside stressors, post traumatic stress disorder, death of a family member or paranoid and anxious behavior for Resident R1.
Clinical record review indicated that on March 11, 2025 the nursing staff found Resident R1 sleepy. The nursing staff member indicated that the resident had to be encouraged to wake up for meals and medication administration. Resident R1 was observed unsteady on her feet while ambulating. The nursing staff indicated that Resident R1 was encouraged to lay down and rest for safety reasons.
Clinical record review indicated that on March 12, 2025 the nursing staff noted Resident R1 was not arousable. The resident was aroused and was then fell back to sleeping. The nursing staff noted that the resident's room smelled of marijuana. Resident R1 was assessed to be lethargic. Resident R1 handed nursing staff a vape pen containing marijuana oil. Resident R1 admitted to using a vape pen containing marijuana oil.
Clinical record review for Resident R1 revealed a psychiatry progress note dated March 21, 2025 that indicated Resident R1 was requesting help with her anxiety symptoms. The psychologist indicated that relaxation techniques were discussed with Resident R1 on March 21, 2025. There was no indication what the relaxation techniques were, when to use or how often. There was no documentation to indicate that any relaxation techniques were added to the care plan to address Resident R1's mental health needs.
Clinical record review indicated that on March 28, 2025 the physician indicated that resident was found intoxicated with marijuana vaping device in her room. The physician indicated that Resident R1 was found to be intoxicated again and her medications Xanax and tramadol would continue to be held; because of the negative, intoxicating and intensified effects of taking these drugs with marijuana.
Interview with Resident R1 at 1:00 p.m., on April 16, 2025 revealed that the resident was unaware how she could cope with her continued anxiety without the use of her as needed Xanax (a benzodiazepine used to treat anxiety or panic disorders). The resident was also speaking about having pain in her right hip and back that she used tramadol (an opiod pain medication) to relieve the pain.
Observations of Resident R1 at 1:00 p.m., on April 16, 2025 revealed that she was feeling nervous about her new roommate. Resident R1 said that she likes to use the fan at night and that her roommate does not like it blowing on her at night, while she was sleeping. Resident R1 was also worried about her lack of treatment of the pain in her lower back: how would this be treated.
Review of Resident R1's clinical record and care plan revealed that there were no interventions developed to address the resident's chronic anxiety disorder and spinal stenosis pain of her back and right hip. Interview with the director of nursing Employee E1, and the licensed practical nurse Employee E3 who was most familiar with the care of Resident R1 at 11:30 a.m., on April 16, 2025 confirmed there was no person centered care plan interventions implemented to meet the preferences and goals of Resident R1 while addressing the medical, mental and psychosocial needs of this resident.
28 PA. Code 211.10(a)(b)(c)(d) Resident care policies
28 PA. Code 211.12(d)(2)(3)(5) Nursing services
28 PA. Code 201.14(a) Responsibility of licensee
Jan 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to ensu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to ensure adequate supervision of two staff members was provided during incontinence care to Resident R1. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip for one of seven residents reviewed. (Resident R1)
Findings include:
Review of facility policy titled Turning and Positioning, revised 2024, revealed assistance must be obtained in turning and repositioning residents/patients who require more than one-person assistance. Do not attempt to turn and reposition by yourself. During care, resident will be turned safely in bed, allowing for proper space to safely turn resident consistent with resident's plan of care.
Clinical record review revealed Resident R1 was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease (lung condition caused by damage of airways that limit airflow), lack of coordination, abnormalities of gait and mobility, and Dementia (progressive degenerative disease of the brain).
Review of Resident R1's Minimum Data Set (MDS- mandated assessment of a resident's abilities and care needs) dated October 14, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment.
Further review of Resident R1's MDS assessment under section G- Functional Status, revealed Resident R1 was assessed as requiring two plus person physical assist for bed mobility. Bed mobility in the MDS assessment is defined as how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture.
Interview on January 21, 2024, at 3:00 p.m. with Employee E2, MDS Coordinator, revealed Resident R1 coded for a two plus person physical assist for bed mobility based on a look back period of nursing aides documentation. The doucmentation revealed Resident R1 required four out of seven days of two plus person physical assist for bed mobility.
Review of Resident R1's care plan dated March 10, 2021 revealed Resident R1 had an ADL (Activities of Daily Living) self care performance deficit. Interventions related to bed mobility included assistance of two staff to turn and/or reposition.
Review of Resident R1's nursing note dated December 28, 2024, at 7:38 p.m. indicated, This nurse was notified by care aide while providing care to resident, resident rolled onto the floor, this nurse notified the nursing supervisor went into the room to assess the resident. Resident had a laceration to the LLE (left lower extremity), and placed a bandage over the site/ neuro checks started. MD (physician) notified.
Continued review of nursing documentation dated December 28, 2024, at 8:17 p.m. revealed, Resident was in bed with a small cut on [his/her] left shin measuring 0.3cm (centimeters) x 0.3 cm Aide then reported the resident rolled out of bed when she turned [him/her] over to change [his/her] brief. Resident c/o (complaint/of) the left arm hurting [her/him]. The nurse assessed the area but no matter where I touched [her/him], [she/he] said it hurt. The on-call physician was notified and ordered x-rays of wrist, elbow, and shoulder to be done immediately.
Review of nursing note dated December 29, 2024, at 5:33 p.m. revealed, at 7:00 p.m. x-ray results were received and revealed an oblique fracture neck of the the left humerus (arm) without dislocation, left wrist possible occult fracture of the med left radius, left hip suspicious for fracture intertrochanteric region left femur (hip) without dislocation.
Review of nursing note dated December 30, 2024, at 7:48 a.m. revealed that Resident R1 was transferred to the hospital via 911 (Emergency Medical Services). Continued review of nursing documentation dated December 30, 2024 at 7:18 p.m. indicated the resident was admitted into the hospital with a diagnosis of proximal end of left humerus.
Review of the facility's investigation into the fall incident sustained by Resident R1 included a typed statement form Nurse aide, Employee E3, which revealed, on 12/28/2024 I was providing care for the resident and asked [her/him] to roll on [her/his] side and as [she/he] turned [herself/himself] rolled out of bed. I called for the nurse.
Interview with Nursing Home Administrator, Employee E1 conducted on January 21, 2024, at 12:30 p.m. revealed that Employee E3 was no longer working at the facility. Employee E3 was not available for interview.
The facility failed to ensure adequate supervision of two staff members was provided to Resident R1 while turning/repositioning resident during incontinence care. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing services
Dec 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility documentation, it was determined that the facility failed to ensure a r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility documentation, it was determined that the facility failed to ensure a resident safe, comfortable and home like environment for 9 out of 9 residents reviewed (Resident R1, R2, R3, R4, R5,R6, R7, R8, and R9).
Finding include:
Review of the facility policy, Environment of Care, with a revision date of September 2024 indicated that the purpose of the policy is to ensure that the facility's building and equipment are repaired in an effect and efficient manner and to ensure a safe and healthful workplace, and to ensure that facility work orders are completed in order of their priority. Review of the policy also indicated that work request should be placed in TELS (a computer system used by facility staff to input repair/replacement request, etc within the facility), and hat a detailed description of the request should be written as well as ensuring that staff assign the appropriate priority to that request (e.g. Low, Medium, Critical). Continued review of the policy indicated that the Environmental Services Director, Maintenance Supervisor or designee will review work order request daily and that emergency work order request will be given priority for making necessary repairs.
Review of information received by the State Survey Agency on November 22, 2024, indicated that requested repairs/replacements inputted in the facility's maintenance computer system were not being addressed in a timely manner.
Review of several work orders with the facility Maintenance Director (Employee E3) on December 9, 2024 at 12:15 p.m. that were submitted by facility staff indicated that the orders that impacted residents care, services and safety, were not addressed in a timely manner:
Review of a work order request with the Maintenance Director on December 9, 2024 at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on November 16, 2024, at 7:16 a.m. for room [ROOM NUMBER], where Resident R1 and Resident R2 resided reporting that the toilet in the room was not flushing properly and that it was overflowing. The work order for the toilet was documented as being Open, indicating that the repair had not been made.
During a tour with the Maintenance Director on December 9, 2024 that began 12:45 p.m. following observations were made regarding the following work order request:
In room [ROOM NUMBER], the Maintenance Director reported that work request that was submitted on November 16, 2024 regarding the inoperable toilet for Resident R1 was addressed last week. The Maintenance Director reported that the tank needs to be replaced. The Maintenance Director also reported that the resident had a concern about his bed was also addressed last week.
During an interview with Resident R1 on December 9, 2024, at 11:29 a.m., the resident reported that his toilet was not working, and he was told that he could use the shower bathroom. Resident reported that he needed help from staff to use this bathroom. During the above referenced interview, the resident reported that his bed quit working and that it would not move up and down and explained that he told multiple people about the toilet and his bed and that it had not been addressed by maintenance staff so his room was moved sometime last week.
A work order request was submitted to the maintenance department by facility staff on December 3, 2024 at 1:47 p.m. reporting that the bed mattress for Resident R9 in room [ROOM NUMBER] was not staying in in place. The work order was marked as Open, indicating that it had not been addressed by maintenance staff.
In room [ROOM NUMBER], Resident R9 reported that someone came in and asked him about his mattress. It was found during the investigation that a maintenance staff member addressed the work order that was submitted on December 3, 2024 regarding the resident's mattress was updated by the Maintenance Director as Completed on December 9, 2024 at 1:32 p.m., 6 days after the request was made.
Review of a work order request with the Maintenance Director on December 9, 2024 at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on December 3, 2024 at 1:51 p.m. reporting that the call bell for room [ROOM NUMBER] where Resident R7 and R8 resided was on outside their room, and cannot be turned off. The work order was marked as Open, indicating that it had not been addressed by maintenance staff.
In room [ROOM NUMBER], the call bell light indicator outside the room was on. Resident R8 entered the room and stated that the call bell for their room had not been working and that both she and her roommate, Resident R7 just got hand-held bells today. Resident R8 entered her room with a hand-held bell for herself and a 2nd one for Resident R7.
Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on August 29, 2024 at 8:01 a.m. reporting that the shower room located on the north side of the 2nd floor needed a new toilet.
The work order was marked as Open, indicating that it had not been addressed by maintenance staff.
In the north 2nd floor shower room, the Maintenance Director reported that the whole toilet has to be replaced and that one will be ordered, but had not been ordered yet.
Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on September 16, 2024 at 8:18 a.m. indicating that the there was water leaking towards the window in front of Resident R5's bed in room [ROOM NUMBER]. The work order was marked as Open, indicating that it had not been addressed by maintenance staff.
In room [ROOM NUMBER], the ceiling tile was removed from the resident's room leaving the ceiling exposed. Pointing to the ceiling, Resident R5 stated no one has done anything about this. The Maintenance Director reported that a plumber will need to come out and make repairs.
Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on November 15, 2024 at 6:40 a.m. indicating that the call light in the room is not working in room [ROOM NUMBER] where Resident R3 and R4 resided. The work order was marked as Open, indicating that it had not been addressed by maintenance staff.
The call light outside room [ROOM NUMBER] was one. Resident R3 and Resident R4 reported that their call bells have been broken and that once she was using the bathroom and had to yell for staff to come ad help her. Resident R3 and Resident R4 reported that they just received hand held call bells, today.
During an interview with the Maintenance Director on December 9, 2024 at 1:30 p.m. it was confirmed that the work orders were not addressed/resolved in a timely manner.
28 Pa. Code 201.18(a) Management
28 Pa. Code 201.18(b)(1)Management
28 Pa. Code 201.18 (b)(3)Management
28 Pa. Code 201.18(d) Management
28 Pa. Code 201.29 (a) Resident Rights
Aug 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 21 residents reviewed (Resident R102).
Fin...
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Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 21 residents reviewed (Resident R102).
Findings include:
A review of Resident R102's quarterly Minimum Data Set (MDS- assessment of resident needs) dated May 15, 2024, revealed that the resident was discharge to hospital. Review of Resident R102's physician discharge summary revealed that the resident was discharged home with family.
An interview with the Registered Nurse Assessment Coordinator, Employee E8, conducted on August 1, 2024, at 11:26 a.m. confirmed that Resident 102's MDS was coded inaccurately.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.5(f) Medical records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and interviews with staff, it was determined that the facility failed to develop and imple...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered plans of care in a timely manner, for three of 21 resident records reviewed (Residents R56, R97 and R71).
Findings include:
Review of Resident R56's clinical record revealed that she was admitted to the facility on [DATE], with the diagnoses of Parkinson's Disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causing hand tremors and difficulty moving).
Review of Resident R56's Annual MDS (Minimum Data Set- assessment of resident's needs) dated June 6, 2024, section title Functional Limitation in Range of Motion revealed that Resident R56 had impairment on both sides for upper extremities.
Observation Resident R56 conducted on July 29, 2024, at 11:30 a.m. revealed that Resident R56's bilateral hands and wrists were observed flexed and contracted and she was not wearing her hand splints which were noted on her bedside nightstand.
Review of Resident R56's physician's orders dated July 12, 2024, revealed an order for BUE (bilateral upper extremity) resting hand splints to be placed on patient after breakfast and removed before lunch daily. Further review of Resident R56's clinical records did not reveal a care plan for the use of bilateral hand splints.
Interview with the Director of Nursing (DON) on August 1, 2024, at 10:20 a.m. confirmed that the resident was not wearing the hand splints, and that the order was for between breakfast and lunch. The DON confirmed that there was no care plan for the use of bilateral hand splints for Resident R56.
Review of Resident R97's clinical record revealed that he was admitted on [DATE], with the diagnoses of Fournier's gangrene (a rare, life-threatening bacterial infection of your scrotum, penis or perineum).
Observation Resident R97 conducted on July 29, 2024, at 11:00 a.m. revealed that Resident R97's had a catheter draining clear yellow urine. When asked about the catheter the resident stated that it had not been changed since his admission and that he was to be discharged soon and would be meeting with his outside surgeon and hoped to have it removed soon.
Review of Resident R97's physician's orders dated June 24, 2024, revealed an order for urinary catheter including daily care, drain catheter bag every shift and PRN (as needed). Further review of Resident R97's clinical records did not reveal a care plan for the use and care of a urinary catheter.
Interview with the Director of Nursing (DON) on July 31, 2024, at 12:30 p.m. confirmed that there was no care plan for the use and care of a urinary catheter for Resident R97.
Review of clinical records for resident R71 revealed that she was admitted to the facility on [DATE], and had diagnoses including, but not limited to, dementia (a condition of progressive cognitive decline), psychosis (a condition where a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), and generalized muscle weakness. Additionally, an MDS (Minimum Data Set- a periodic assessment of resident needs) from July 7, 2024, reported in section O (Special Treatments and Programs) that the resident was receiving hospice care while at the facility.
Continued review revealed a physician order from July 25, 2024, which stated Hospice services for DX (diagnosis) End Stage Senile Dementia. Review of the care plan for resident R71 revealed that no care plan had been developed for the resident's hospice care as of August 1, 2024.
Interview with the DON and the Nursing Home Administrator (NHA) at 2:00 p.m. on August 1, 2024, revealed that it is the expectation of the facility to develop a care plan for all residents entering into hospice care.
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide restorative nursing programs for one of 21 residents reviewed (Residents R56).
Findings include:
Review of Resident R56's clinical record revealed that she was admitted on [DATE], the diagnoses of Parkinson ' s Disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causing hand tremors and difficulty moving).
Review of Resident R56's Annual MDS (Minimum Data Set- assessment of resident's needs) dated June 6, 2024, section title Functional Limitation in Range of Motion, revealed that Resident R56 had impairment on both sides for upper extremities.
Observation of Resident R56 conducted on July 29, 2024, at 11:30 a.m. revealed that Resident R56's bilateral hands and wrists were observed flexed and contracted and she was not wearing her hand splints which were noted on her bedside nightstand.
Review of Resident R56's physician ' s orders dated July 12, 2024, revealed an order for BUE (bilateral upper extremity) resting hand splints to be placed on patient after breakfast and removed before lunch daily.
Observation of Resident R56 on July 30, 2024, at 11 a.m. revealed that the resident was sitting in her wheelchair at the foot of her bed and was not wearing her hand splints, which were on her nightstand.
Observation of Resident R56 on July 31, 2024, at 10:48 a.m. revealed that the resident was sitting in her wheelchair and not wearing her hand splints, which were sitting on the nightstand. Interview with Nurse aide, Employee E8, revealed that Resident R56 was not on her usual assignment, and that she was unaware that the resident was to be wearing her hand splints between breakfast and lunch.
Observation of Resident R56 on August 1, 2024, at 10:00 a.m. revealed that the resident was sitting in her wheelchair and not wearing her hand splints.
Interview with the Director of Nursing (DON) on August 1, 2024, at 10:20 a.m. confirmed that the resident was not wearing the hand splints, and that the order was for between breakfast and lunch, and that the facility was in the process of training the CNA staff for performing these restorative nursing orders. The DON interviewed Employee E9, CNA who ' s regular shift is 3 p.m. to 11 p.m. and who stated that she was unaware of placing the hand splints on Resident R56 after breakfast even though it was on Resident R56 ' s care card.
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E4).
Findings includ...
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Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E4).
Findings include:
An interview on July 29, 2024, at 9:15 a.m. with Employee E4, Food Service Director (FSD), revealed that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that he was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that he had not received frequently scheduled consultations from a qualified dietitian.
A review of Employee E4's credentials revealed that Employee E5 did not meet the statutory qualifications of a director of food and nutrition services.
During an interview on August 1, 2024, at 12:50 p.m. with the Administrator, the FSD's personnel file was reviewed, and his qualifications were discussed which revealed he had not yet completed his program and had not taken the exam for Certified Dietary Manager or Certified Food Manager. The Administrator confirmed that the FSD had not completed these requirements.
The Nursing Home Administrator was unable to provide evidence that the FSD was Certified, and therefore unqualified to direct the dietary department.
28 Pa Code 201.18(e)(1)(6) Management
28 Pa. Code 211.6(c)(d) Dietary services
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the pr...
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Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for 18 of 18 residents interviewed (Residents R79, R89, R65, R39, R30, R97, R64, R35, R74, R21 R62, R53, R78, R88, R28, R27, R22 and R66.)
Findings include:
A review of the undated Test Tray Evaluation form revealed that the standard temperature range for milk and cold beverage were 41° F.
A test tray was conducted at the lunch meal on July 30, 2024, at 12:15 p.m. with the Food Service Director (FSD), which revealed that the carton of whole milk was served at 57 degrees. Upon tasting the milk tasted warm, and the baked ziti was not baked, but rather just mixed with the meat sauce and the noodles were overcooked and very soft and the meat sauce had an off sweet flavor, the mixed vegetables were very overcooked with the squash so soft the it could not be picked up with a fork, it just fell apart. The FSD confirmed that the milk should be at or below 41 degrees, and that 57 degrees was not acceptable.
Resident interviews during the initial tour of the second floor North Hall on July 29, 2024, beginning at 10:05 a.m. revealed the following:
Interview at 10:15 a.m. with Resident R79 revealed that he felt that the food sucks, he said that they don't send juice, but rather milk, he thinks they run out of juice all the time.
Interview at 10:20 a.m. with Resident R89 revealed that she is not getting what is on the ticket, especially she is not getting the breakfast meats like ham yesterday of sausage the other day, which they are on the ticket, but she does not get it. The other day the ticket said coffee, but she did not get it. The resident indicated that she is very frustrated and feels like they don't listen to her or care.
Interview at 10:27 a.m. with Resident R65 revealed that he is a diabetic and he feels that he is getting too much starch in foods like white rice, macaroni, pancake, waffles, etc. and he is concerned for his health.
Interview at 10:32 a.m. with Resident R39 revealed that he is getting regular milk, and he should be getting lactose free milk every meal, and he prefers blueberry yogurt, but never gets that.
Interview at 10:35 a.m. with Resident R30 revealed that she felt that the food has too much gravy on everything, and she wants whole milk with breakfast and supper, and that she does not like fish or rice and is receiving these items.
Interview at 10:38 a.m. with Resident R97 revealed that he is not getting what is on the ticket, was supposed to get pancakes the other day, it is on the ticket, but he does not get it on his plate.
Interview at 10:44 a.m. with Resident R64 revealed that he felt that the food sucks, he said that it is so bad that he will go days without eating, and he is tired of always spending his money, he should not have to buy his own food.
Interview at 10:50 a.m. with Resident R35 revealed that she felt that the food is usually too spicy for her, that she doesn't want pork and shouldn't have dairy products, tomatoes, nuts, or eggs and yet she says she gets these items regularly.
A group meeting held at 10:11 a.m., on July 31, 2024, with alert and oriented residents (R74, R21 R62, R53, R78, R88, R28, R27, R22 and R66.) revealed that these residents were unsatisfied with the taste and temperature of the food and beverages that were being served for breakfast, lunch, and dinner daily. Food is usually dry meat, a lot of gravy, overcooked vegetables, and overcooked food.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 211.1 Dietetic Services, Principle
Aug 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on a review of the grievance policy, review of facility documentation, and interviews of residents and facility staff, it was determined that the facility failed to resolve a grievance related t...
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Based on a review of the grievance policy, review of facility documentation, and interviews of residents and facility staff, it was determined that the facility failed to resolve a grievance related to the resident's personal property in a timely manner for three of 22 residents reviewed. (Residents R12, R86, and R76).
Findings include:
Review of the facility's policy labeled Resident's Personal Belongings, effective July 2023, indicated that the clothing should be labeled by resident's representative or facility representative and then listed on the inventory sheet. A thorough investigation will be conducted if items are reported missing or damage, and the facility will not be responsible unless the damage or loss was identified as cause by the action of the facility's employee(s) or facility systems. Under Missing personal property states Any repot of missing personal property will result in the initiation of grievance form which will be given to Social Services, administrator, or grievance official. The facility's concern procedure will then be initiated.
An interview was held on July 31, 2023, at 11:37 a.m. with Resident R12 who reported that he had clothing missing lot of clothing, 20 pairs of underwear, 2 pair of shorts with buttons.
An interview was conducted on August 1, 2023, 1:38 p.m. with Social Worker, Employee E7, who reviewed a grievance initiated on April 18, 2023, for the personal clothing missing. Based on the investigation facility determined to reimburse Resident R12 for the missing item of a total of $306.00. Grievance was marked as resolved on May 4, 2023. Further investigation revealed that resident did not receive the reimbursement check as of August 1, 2023.
Interview with the Nursing Home Administrator (NHA) on August 2, 2023, at 1:05 p.m. confirmed that there was no documented evidence to show Resident R12 received reinbursement for persobnal clothing. A check was overnighted on August 1, 2023, and Resident R12 received his check on August 3, 2023. NHA reported that all of her staff were reeducated on August 1, 2023 about resident missing items and process in reimbursement.
An interview with Resident R86 on July 31, 2023, at 11:15 a.m. revealed that Resident R86 had no clothing to wear, and all of her clothing was to the laundry last week. Observation of the clothing in Resident R86's closet confirmed that Resident R86 had no clothing and was wearing a hospital gown.
An interview with Resident R76 on July 31, 2023, at 12:01 p.m. revealed that R76 had no clothing to wear and was wearing a hospital gown. Observation of clothing in R76's closet confirmed that R76 had no clothing.
An interview with the housekeeping director, Employee E25, on July 31, 2023, at 12:05 p.m. revealed a person who was doing personal laundry quit last week and now there was one staff doing laundry.
An interview with NHA on July 31, 2023, at 12:38 p.m. revealed that one washing machine was down last Thursday, July 27, 2023 and it was fixed Friday July 28, 2023 and resident's clothing needing to be washed was backed up. Validation of documentation of the washing machine was requested multiple times and it was not provided to validate the damage.
Tour of facility's laundry room on August 1, 2023 at 1:43 p.m., with laundry director, employee E24, revealed the unlabeled blanket for Resident R5 prepared to be delivered back to Resident R5.
During the resident council meeting, which was held on August 2, 2023, at 10:30 a.m. with 23 alert and oriented residents R74, R35, R72, R27, R52, R30, R93, R3, R85, R64, R4, R38, R77, R16, R3,R83, R45, R73, R86, R87, R41, R18 revealed six of the residents were still were missing clothing from laundry .
28 Pa. Code: 201.14 (a) Administrator's responsibility
28 Pa. Code: 201.18 (b) (3) Management
28 Pa. Code: 201.29(j) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of policies, review of personnel files, and staff interviews, it was determined that the facility failed to complete an employment reference verification upon hire for five of five new...
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Based on review of policies, review of personnel files, and staff interviews, it was determined that the facility failed to complete an employment reference verification upon hire for five of five newly hired employees reviewed (Employee E17, E18, E19, E20, E21).
Findings include:
The facility's policy regarding abuse and screening potential employees, revised March 2023, revealed that under screening procedures potential employees will be screened, per federal &/or state regulation, during the hiring process for history of abuse, neglect, or mistreatment of residents. Screening will consist of inquiring. Into the State licensing authorities, inquiries into State nurse aide registry, reference checks from previous and/or current employers, criminal background checks will be completed to identify any potential employee unfit to work in LTC, resulting of the screening will be recorded to include the date, name and title of person contacted for reference, and name of person obtaining the reference. This document is filled with other employee records.
The personnel file for license nurse, Employee E17 revealed that she was hired on June 28, 2023; license nurse, Employee E18, hired on June 20, 2023; nurse aid, Employee E19, hired on May 23, 2023; Dietary aide, Employee E20, hired on April 25, 2023, and Maintenance Director, Employee E21, hired on April 11, 2023. As of August 3, 2023, there was no documented evidence that the newly hired employees references were verified prior to hire.
Interview with the Nursing Home Administrator on August 3, 2023, at 9:46 a.m. confirmed that there was no documented evidence of a reference, prior to employment, being completed as required upon hire for Employees E17, E18, E19, E20, E21.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(e)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergen...
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Based on review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required for three of three months reviewed. (May, June and July 2023)
Findings include:
Documentation of notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past three months (May, June and July 2023) was requested on August 3, 2023, at 11:05 a.m. from Employee E1, Nursing Home Administrator (NHA).
Interview with NHA on August 3, 2023, at 12:15 p.m. confirmed that the facility did not send the notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past three months. She indicated that this function was to be performed by a new employee in the business office, but that the person was not instructed to send these notices. Continued interview revealed that the NHA was not aware that the new employee was not sending the required notices to the Office of the State Long-Term Care Ombudsman.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(2) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and review of the Resident Assessment Instrument and staff interview, it was determined th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and review of the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two out of 22 sampled resdients (Residents R97 & R98).
Findings included:
A review of Resident R97's Discharge MDS assessment dated [DATE], Section A2100 Discharge Status revealed that Resident R97 was coded 01 Community (private home/apartment, boarding home, assisted living, group home) or discharged home.
Review of Resident R97's clinical record revealed a June 7, 2023, progress note written at 11:30 p.m. documenting that the resident was taken by ambulance to the hospital to be evaluated and indicating that the discharge MDS was not accurate.
Interview with the Registered Nurse Assessment Coordinator (RNAC) on August 3, 2023, at 11:05 a.m. revealed that she was unsure when she coded the MDS as she was informed that Resident R97 was taken to jail.
Interview with the Director of Nursing on August 3, 2023, at 11:07 a.m., confirmed that Resident R97's discharge MDS should have been coded 03 Acute Hospital as he left the facility in an ambulance and was taken to the hospital for evaluation before being arrested and taken to jail, making the MDS inaccurate.
A review of Resident R98's Discharge MDS assessment dated [DATE], Section A2100 Discharge Status revealed that Resident R98 was coded 03 Acute Hospital.
Review of Resident 98's clinical record revealed a June 9, 2023, progress note written at 4:00 p.m. documenting that the resident was discharged home awake and alert with all belongings and medications leaving the unit with his responsible party and indicating that the discharge MDS was not accurate.
Interview with the Registered Nurse Assessment Coordinator (RNAC) on August 3, 2023, at 11:00 a.m. revealed that she was confused when she coded the MDS as Resident R98 was recently hospitalized , but that it should have been coded 01, Community as he was discharged home with his family.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.5(f) Clinical Records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, clinical record review, staff interview, review of facility policy and interview with residents, it was determined that the facility to ensure that a breathing medication was pr...
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Based on observations, clinical record review, staff interview, review of facility policy and interview with residents, it was determined that the facility to ensure that a breathing medication was provided as ordered byt the physician for one of 22 residents reviewed (Resident R88)
Findings include:
Review of facility's policy for 'Medication Administration' revised on September 2018, states: If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the medication administration record (MAR) for that dosage administration is initiated and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Additional review of policy revealed The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.
Review of Resident R88's clinical records revealed diagnosis of chronic obstructive pulmonary disease (COPD - difficulty breathing), anemia (when your blood produces a lower-than-normal amount of healthy red blood cells), heart failure.
Review of Resident R88's physicians orders revealed an active order placed on July 26, 2023 for Incruse Ellipta Inhalation Aerosol Powder Breath activated 62.5 mcg/act to use 1 puff inhale orally one time a day for asthma/COPD.
Interview with Resident R88 on August 1, 2023 at 1:58 p.m., revealed that he has not been receiving a stronger congestion medication. Resident R88 stated that he has been prescribed an inhaler which he has not been receiving consistently, and only received it twice.
Review of Resident R88's electronic MAR revealed that Incruse inhaler administration has been administered and signed out by licensed nurse, each day since an order was placed on July 26, 2023. However, observation of Resident R88's Incruse inhaler dose counter revealed number 28 on August 2, 2023. According to Incruse Ellipta inhaler manufacturer's product information regarding dose counter, before the inhaler has been used, it shows exactly 30 doses. It counts down by 1 each time you open the cover. Finding confirmed with Licensed nurse, Employee E17.
28 Pa Code 211.2(c) Nursing services
28 Pa Code 211.2(d)(1) Nursing services
28 Pa Code 211.2(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observations, clinical record review and interviews with staff, it was determined that the facility did not ensure that a resident received appropriate treatment services for contracture mana...
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Based on observations, clinical record review and interviews with staff, it was determined that the facility did not ensure that a resident received appropriate treatment services for contracture management as recommended for one out of 22 residents reviewed (Resident R49)
Findings include:
Review of Resident R49's clinical records revealed diagnosis of stiffness of left shoulder, stiffness of left elbow, contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of left knee, contracture of left hip, contracture of left hand, and contracture of left thigh.
Review of 'Therapy Recommendations for Restorative/Functional Maintenance Program, completed by occupational therapist, Employee E25, on April 12, 2023, revealed the following: Resting hand splint on left UE (upper extremity) - 9AM to noon, daily, or as tolerated by patient. Skin check before application of resting hand splint - and upon removal of hand splint.
Review of Resident R49's orders revealed an active order placed on January 26, 2021, by unit manager, Employee E26, to apply left hand splint at bedtime daily, inspect skin under splint and document. Additional order placed on January 26, 2023 revealed Remove L (left) hand splint daily in AM. Inspect skin under splint. Document.
Review of Resident R49's care plan revealed focus on Range Of Motion: the resident has a risk or actual limitations in Range of Motion as evidence by; contracture to left UE, with an intervention to Splint to UE daily on at 9am, removed at 12 noon or as tolerated by resident.
During medication administration observation on August 1, 2023, at 9:42 a.m., Resident R49 was observed without the hand splint. Resident R49 stated that she has two hand splints which were in her bedside drawer and that she was unsure when to use the hand splint on the contractured hand. Additional observation of the electronic medication administration record revealed that licensed nurse, Employee E17, signed out treatment for left hand splint removal on August 1, 2023. Upon interview, Employee E17 stated that nurse aide probably removed left hand splint during morning care. Employee E17 confirmed that Resident R49 is to have left hand splint applied overnight and removed in the morning.
Additional interview with Licensed nurse, Employee E23, on August 2, 2023 at 10:28 a.m. revealed that she follows physicians orders over occupational therapist recommendations as mentioned in Resident R49's care plan.
Additional interview with facility's resident assessment coordinator on August 2, 2023 at 11:00 a.m., revealed that recommendation from occupational therapist to apply splint from 9 a.m. to noon was not incorporated into Resident R49's orders; resulting in miscommunication between nursing staff regarding timing and duration of left hand splint application.
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.
Finding include:
A tour of the Food Service Depar...
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Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.
Finding include:
A tour of the Food Service Department conducted on July 31, 2023, at 10:45 a.m. with the Food Service Director (FSD), Employee E4, revealed the following concerns:
Observation in the back of the facility revealed that the dumpster area had seven old mattresses leaning against the dumpster, which was missing a lid on one side of the top leaving the trash inside exposed and the slider door was not closed all the way. Further observation revealed a lot of debris around the dumpsters including used latex gloves, paper and plastic waste.
An interview with the FSD on July 31, 2023, at 10:55 a.m. confirmed the above findings.
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 207.2(a) Administrator's responsibility
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for...
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Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.
Findings include:
A tour of the Food Service Department conducted on July 31, 2023, at 10:45 a.m. with the Food Service Director (FSD), Employee E4, revealed the following concerns:
Observation in the dry food and paper storage area revealed a broken ceiling tile.
Observations in the dish room area revealed a big box under the dish table, which was a Hatco booster heater that was no longer in use which was dusty and dirty, and the top cover was rusted through creating a sharp-edged opening to the inside electrical components and the surrounding pipes and table legs were dusty and soiled.
Observations in the kitchen revealed dirty and broken ceiling tiles above the coffee urn and which was missing the top cover, and the shelf under the coffee urn was dusty and the paint was peeling from the surface revealing rust colored substance.
Observations in the kitchen revealed an HVAC vent with white peeling paint hanging from the surface.
Observation in the hot production area revealed a dirty wall behind the stove with dark splashed on food debris sticking to the wall and baseboard.
Observation of the milk refrigerator revealed that the milk crates were in at least one inch of standing water.
Interview with the FSD on July 31, 2023, at 10:55 a.m. confirmed the above findings.
28 Pa. Code 201.14(a) Responsibility of licensee
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 harm violation(s), $112,875 in fines. Review inspection reports carefully.
- • 24 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $112,875 in fines. Extremely high, among the most fined facilities in Pennsylvania. Major compliance failures.
- • Grade F (25/100). Below average facility with significant concerns.
Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Onyx Wellness Center's CMS Rating?
CMS assigns ONYX WELLNESS CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Onyx Wellness Center Staffed?
CMS rates ONYX WELLNESS CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 64%, which is 18 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Onyx Wellness Center?
State health inspectors documented 24 deficiencies at ONYX WELLNESS CENTER during 2023 to 2025. These included: 1 that caused actual resident harm, 22 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Onyx Wellness Center?
ONYX WELLNESS CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PARAMOUNT CARE CENTERS, a chain that manages multiple nursing homes. With 119 certified beds and approximately 108 residents (about 91% occupancy), it is a mid-sized facility located in NORRISTOWN, Pennsylvania.
How Does Onyx Wellness Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, ONYX WELLNESS CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (64%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Onyx Wellness Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Onyx Wellness Center Safe?
Based on CMS inspection data, ONYX WELLNESS CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Onyx Wellness Center Stick Around?
Staff turnover at ONYX WELLNESS CENTER is high. At 64%, the facility is 18 percentage points above the Pennsylvania average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Onyx Wellness Center Ever Fined?
ONYX WELLNESS CENTER has been fined $112,875 across 2 penalty actions. This is 3.3x the Pennsylvania average of $34,208. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Onyx Wellness Center on Any Federal Watch List?
ONYX WELLNESS CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.