48 Reports
Inspection Report — Apr 10, 2026
Complaint Investigation
Date: Apr 10, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the Norbert Residential Care Facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 7
Inspection Report — Feb 25, 2026
Complaint Investigation
Date: Feb 25, 2026
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident.
Complaint Details
The inspection was complaint-related and incident-related, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 6
Inspection Report — Jan 30, 2026
Follow-Up
Date: Jan 30, 2026
Visit Reason
The inspection visit was a partial, unannounced follow-up triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have unsubstantiated allegations of resident abuse due to failure to report in a timely manner, privacy violations related to video recording in common areas, snow and ice removal deficiencies on emergency exit paths, and incomplete resident support plans regarding medical needs and signatures. Corrective actions including staff re-education, audits, and policy updates were implemented and verified.
Citations (6)
2600.15a The home failed to immediately report suspected resident abuse to the local Area Agency on Aging after an allegation was made at approximately 1:45am.
2600.16c The home did not report the incident of alleged physical abuse to the Department within 24 hours, reporting it only at approximately 10:45am.
2600.42s The home was video recording in common areas including hallways near resident bedrooms and exterior entrances, inconsistent with posted signage about 24-hour monitoring.
2600.100b The home failed to remove snow and ice from sidewalks and steps leading to emergency exits, with 6 inches on a sidewalk and 4 inches on steps observed during inspection.
2600.227d Resident support plans did not include plans to meet medical needs for multiple diagnoses and did not indicate use of mobility devices such as walker and wheelchair.
2600.227g Resident support plans were not signed by the resident and did not document if the resident was unable or refused to sign.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 6
Residents Age 60 or Older: 57
Residents with Mobility Need: 31
Inspection Report — Dec 3, 2025
Complaint Investigation
Date: Dec 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the Norbert Residential Care Facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 62
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 9
Inspection Report — Sep 10, 2025
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 9
Residents Age 60 or Older: 60
Residents with Mobility Need: 33
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 1
Inspection Report — Jul 30, 2025
Renewal
Date: Jul 30, 2025
Visit Reason
The inspection was conducted as a renewal visit with a new license issued, including a capacity revision for the Secured Dementia Care Unit.
Findings
The facility was found to have several deficiencies including obstructed emergency egress, unlabeled resident medications, lack of resident education on medication refusal rights, incomplete resident assessments, and missing posted directions for locking devices. All deficiencies had plans of correction accepted and were implemented by August 22, 2025.
Citations (5)
Dining room table obstructed emergency exit door pathway on the third floor of the secured dementia care unit.
Resident #1's insulin Lispro Kwik pen lacked original pharmacy label including date issued, dosage, instructions, and prescriber information.
Residents #1 and #2 were not educated on their right to refuse medication if they believed there was a medication error.
Resident #3's initial assessment did not include multiple diagnoses as indicated on medical evaluation.
Directions for operating the home's locking mechanism were not conspicuously posted near the emergency exit door in the secured dementia care unit.
Report Facts
Residents Served: 60
Total Daily Staff: 92
Waking Staff: 69
Residents in Secured Dementia Care Unit: 15
Hospice Residents: 8
Residents 60 Years or Older: 59
Residents with Mental Illness: 4
Residents with Intellectual Disability: 2
Residents with Mobility Need: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed letter approving revised license and capacity. |
| Maintenance Director | Responsible for posting directions for locking mechanisms and auditing locking devices. | |
| DON | Director of Nursing | Placed insulin medication labels, educated medication technicians, and audited insulin medications. |
| Assistant to the Administrator | Updated resident #3 assessment and educated DON on assessment requirements. | |
| PCHA | Reconfigured dining tables and educated clinical staff on emergency egress. |
Inspection Report — Mar 20, 2025
Complaint Investigation
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation at Norbert Residential Care Facility on 03/20/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 8
Resident Count - Receive Supplemental Security Income: 1
Resident Count - Diagnosed with Mental Illness: 4
Resident Count - Have Mobility Need: 33
Resident Count - Are 60 Years of Age or Older: 58
Resident Count - Diagnosed with Intellectual Disability: 2
Resident Count - Have Physical Disability: 1
Total Daily Staff: 92
Waking Staff: 69
Inspection Report — Apr 25, 2024
Complaint Investigation
Date: Apr 25, 2024
Visit Reason
The inspection was conducted due to an incident involving medication administration errors and staff abandonment of shift at the Norbert Residential Care Facility.
Complaint Details
The visit was complaint-related due to an incident where a medication technician abandoned their shift and medications were not administered to approximately 26 residents. The complaint was substantiated with findings of medication errors and failure to document administration properly.
Findings
Approximately 26 residents did not receive their evening medications on 4/24/2024 due to a medication technician abandoning their shift and the other technician failing to administer medications as instructed. The facility took corrective actions including termination of involved staff, re-education of medication technicians, and ongoing monitoring to ensure compliance.
Citations (3)
Failure to administer medications to approximately 26 residents on the evening of 4/24/2024 due to staff abandonment and non-compliance.
Failure to record medication administration accurately in electronic medication administration records (E-MAR) for April 2024 for affected residents.
Failure to follow prescriber's orders for medication administration for approximately 26 residents on 4/14/2024.
Report Facts
Residents affected by medication error: 26
Residents served at inspection: 50
Total daily staff: 72
Waking staff: 54
Inspection Report — Dec 15, 2023
Complaint Investigation
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 12/15/2023 to review compliance related to a submitted plan of correction.
Complaint Details
The visit was complaint-related, with the complaint substantiated by findings of inadequate additional assessments for a resident with significant health decline and wound care needs.
Findings
The inspection found that the submitted plan of correction was fully implemented. The main deficiency involved failure to conduct additional assessments when a resident's condition significantly changed, specifically related to hospice care and wound management for a resident with multiple wounds and increased care needs.
Citations (1)
Failure to complete additional assessments for a resident whose condition significantly declined, requiring increased hospice services and wound care.
Report Facts
Residents Served: 54
Secured Dementia Care Unit Residents Served: 4
Hospice Current Residents: 7
Residents Age 60 or Older: 53
Residents with Mobility Need: 23
Residents with Physical Disability: 4
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 3
Total Daily Staff: 77
Waking Staff: 58
Resident Wounds: 8
Plan of Correction Follow-Up Date: Jan 26, 2024
Inspection Report — Jul 6, 2023
Original Licensing
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as a licensing inspection of the Norbert Residential Care Facility on 07/06/2023.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 48
Current Hospice Residents: 7
Resident Support Staff: 0
Total Daily Staff: 70
Waking Staff: 53
Residents Receiving Supplemental Security Income: 2
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 22
Residents Age 60 or Older: 48
Residents Diagnosed with Intellectual Disability: 3
Residents with Physical Disability: 2
Inspection Report — Feb 21, 2023
Complaint Investigation
Date: Feb 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and to verify the submitted plan of correction.
Complaint Details
The visit was complaint-related, triggered by concerns about resident supervision and care. The submitted plan of correction was accepted and found fully implemented.
Findings
The inspection found deficiencies related to inadequate supervision and support plans for residents with wandering and fall risks, incomplete medical evaluations missing resident weight, and support plans not updated to reflect current resident needs including hospice care. The facility submitted and implemented a plan of correction addressing these issues.
Citations (3)
Resident wandering and fall risks were not adequately addressed in assessments and support plans, including lack of proper supervision and use of wander guards.
Medical evaluations for residents did not include required information such as resident weight.
Support plans were not revised timely to reflect changes in resident needs, including supervision, fall risk, and hospice care services.
Report Facts
Residents Served: 58
Current Residents Receiving Hospice: 11
Residents with Mobility Need: 28
Residents 60 Years or Older: 58
Total Daily Staff: 86
Waking Staff: 65
Inspection Report — Sep 24, 2022
Complaint Investigation
Date: Sep 24, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations of abuse and neglect reported by the local Area Agency on Aging.
Complaint Details
The complaint investigation was triggered by an onsite investigation by the local Area Agency on Aging on 09/09/2022 regarding allegations of abuse and neglect. The allegations were found to be unsubstantiated. The facility was directed to submit a report and implement corrective actions.
Findings
The investigation found that allegations of abuse and neglect were unsubstantiated but identified deficiencies related to failure to report incidents timely and excessive wait times for staff assistance to residents. A plan of correction was submitted and fully implemented.
Citations (2)
Failure to report allegations of abuse and neglect to the Department within 24 hours as required.
Excessive wait times for staff assistance to residents, with documented call bell response times ranging from 38 minutes to over 3 hours.
Report Facts
Residents Served: 61
Current Hospice Residents: 8
Residents Age 60 or Older: 61
Residents with Mobility Need: 31
Residents with Mental Illness: 2
Residents Receiving Supplemental Security Income: 1
Residents with Physical Disability: 1
Total Daily Staff: 92
Waking Staff: 69
Inspection Report — Nov 4, 2021
Renewal
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing requirements and complaint allegations.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit: Renewal, Complaint.
Findings
The inspection identified multiple deficiencies related to staff criminal background checks, staff qualifications, orientation and training, medication management, and resident safety. Plans of correction were submitted but not accepted, with ongoing follow-up and monitoring required.
Citations (12)
A Pennsylvania criminal background check was not completed for staff person A and staff person B.
Direct care staff person B lacked required qualifications including high school diploma or nurse aide registry status.
Direct care staff persons did not provide the required minimum hours of personal care services on 10/24/21.
Staff persons B, C, and D did not receive required fire safety orientation prior to or during their first work day.
Staff persons B, C, and D did not receive required orientation on resident rights, emergency medical plan, and mandatory abuse reporting within 40 scheduled working hours.
Direct care staff person B did not complete and pass the Department-approved direct care training course and competency test.
No operable lamp or other source of lighting that could be turned on/off from bedside was present at resident's bed in bedroom #210.
Resident #4 had an expired eye medication (Latanoprost 0.005%) that was not discarded within the required timeframe.
Glucometers for residents #1, #2, #3, #4, #5, and #6 were not set to the correct date and/or time, and blood glucose readings were inconsistently documented.
Residents' medication administration records (MARs) lacked a master key with staff names and initials, and some medications lacked diagnosis or purpose.
Direct care staff persons E and F documented medication administration late, not at the time medications were given.
Resident #1 did not receive the correct insulin dose according to blood glucose readings, and Resident #6 missed blood glucose checks during meals.
Report Facts
Residents Served: 72
Staffing Hours: 100
Waking Staff: 75
Residents with Mobility Needs: 28
Deficiencies Cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member B | Named in multiple findings related to missing criminal background check, lack of qualifications, missing orientation and training, and incomplete direct care training. | |
| Staff Member C | Named in findings related to missing orientation and training. | |
| Staff Member D | Named in findings related to missing orientation and training. | |
| Staff Member E | Observed documenting medication administration late. | |
| Staff Member F | Observed documenting medication administration late. | |
| Michael Marini | Lead Inspector | Conducted the on-site inspection visit. |
| Larry Mazza | Reviewer | Reviewed plans of correction and follow-up submissions. |
| Roseann Rosnick | Administrator | Facility administrator listed in report. |
Notice — Sep 13, 2021
Date: Sep 13, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Norbert Residential Care Facility following receipt of the renewal application dated August 24, 2021. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — Jun 23, 2021
Complaint Investigation
Date: Jun 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation at Norbert Residential Care Facility on 06/23/2021.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified during this complaint investigation inspection.
Report Facts
Residents Served: 59
Current Hospice Residents: 10
Residents Age 60 or Older: 59
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 23
Inspection Report — Jun 9, 2021
Complaint Investigation
Date: Jun 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of neglect and other concerns at Norbert Residential Care Facility.
Complaint Details
The complaint involved an allegation of neglect of resident #1's care and a denial of visitation to resident #2's family member. The neglect allegation was not reported to the Department as required.
Findings
The inspection found multiple deficiencies including failure to report an allegation of neglect, denial of visitation rights, and issues with unobstructed egress and exit signage. Plans of correction were accepted and implemented.
Citations (4)
Failure to report an allegation of neglect of resident #1's care to the Department.
Denial of face-to-face visitation to a family member of resident #2, contrary to resident rights.
A 2" by 4" board obstructed the door leading out of the exterior fenced smoking area, making it difficult to open.
No exit sign over the fire exit door from the 4th floor hallway by the elevator to the outside smoking area.
Report Facts
Residents served: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Surveyor | Signed letters regarding inspection and plan of correction |
| Administrator | Named in neglect reporting deficiency and plan of correction | |
| Director of Nursing | Director of Nursing | Involved in educational session regarding mandatory reporting |
| Deputy Fire Marshal | Deputy Fire Marshal for the City of Pittsburgh | Consulted regarding egress and exit signage deficiencies |
Inspection Report — May 4, 2021
Renewal
Date: May 4, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Apr 14, 2021
Complaint Investigation
Date: Apr 14, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Norbert Residential Care Facility.
Complaint Details
The visit was complaint-related, focusing on the refund policy for admission fees. The complaint was substantiated by the finding that the refund was not issued as required.
Findings
The inspection found a violation related to the facility's refund policy for admission fees, specifically a failure to issue a refund to a resident's power of attorney after the resident's death. The submitted plan of correction was reviewed and determined to be fully implemented.
Citations (1)
Failure to issue a refund of the Community Fee to the resident's power of attorney after the resident's death.
Report Facts
Residents Served: 56
Community Fee: 500
Inspection Report — Jan 27, 2021
Follow-Up
Date: Jan 27, 2021
Visit Reason
The visit was a follow-up inspection to review the submitted plan of correction related to a prior incident at the facility.
Complaint Details
The visit was related to a complaint incident involving abuse of a resident by staff person A. The staff member was terminated following investigation. Abuse training was conducted for all staff and additional measures were implemented to prevent recurrence.
Findings
The submitted plan of correction was determined to be fully implemented. The facility was found to have addressed the cited deficiencies, including staff training on mandatory abuse reporting and termination of the involved employee.
Citations (1)
Resident #1 was verbally and physically abused by staff person A, who dragged the resident and used inappropriate language.
Report Facts
Residents Served: 53
Current Hospice Residents: 7
Residents Age 60 or Older: 52
Residents with Mental Illness: 5
Residents with Intellectual Disability: 1
Residents with Mobility Need: 18
Residents Receiving Supplemental Security Income: 2
Inspection Report — Jan 13, 2021
Complaint Investigation
Date: Jan 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced review of Norbert Residential Care Facility on 01/13/2021 through 01/15/2021.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the partial, unannounced nature of the inspection.
Findings
The inspection found deficiencies related to improper use of personal protective equipment by staff, failure to provide residents with assistance for activities of daily living as per their care plans, and unsanitary conditions including buildup of dust and debris on heating units. Plans of correction were submitted and accepted with training and cleaning schedules implemented.
Citations (4)
Staff persons were observed entering and exiting resident bedrooms without the use of gloves or hand sanitizing between rooms while removing trash, violating infection control protocols.
Resident #1 did not receive required assistance with showers and urostomy care as indicated in the care plan, and staff delayed response to call bell for medical device assistance.
Resident #2, a fall risk, fell in the restroom and was not assisted despite pulling the emergency cord approximately fifty times.
There was a buildup of approximately ¼ inch of dust and grey matter on the PTAC heating unit screen in resident #3's bedroom, and the unit was not cleaned despite staff acknowledgment.
Report Facts
Residents Served: 54
Current Hospice Residents: 7
Residents with Mobility Need: 18
Residents 60 Years or Older: 53
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 1
Residents Receiving Supplemental Security Income: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jon Kimberland | Signed the letter confirming plan of correction implementation | |
| RN | Provided staff training on proper use of PPE, DME, RASP, and daily care documentation | |
| Maintenance Director | Responsible for quarterly cleaning and documentation of PTAC units |
Inspection Report — Oct 5, 2020
Routine
Date: Oct 5, 2020
Visit Reason
The inspection was a full, unannounced licensing inspection conducted on 10/05/2020 and 10/06/2020 to assess compliance with Department of Human Services regulations at Norbert Residential Care Facility.
Findings
The inspection identified multiple deficiencies including lack of resident telephone access, incomplete staff training records, uncovered trash receptacles, untimely medical evaluations, missing current activity calendar, incomplete preadmission screening forms, and restricted access to resident support plans. Plans of correction were accepted or directed with specified completion dates.
Citations (8)
42e - Telephone Access: Residents do not have access to a telephone in the home to make calls in privacy. The facility is implementing policies and procedures to ensure telephone access without requiring permission.
65i - Training Record: The home's record of direct care staff training for 2019 does not indicate the date certain trainings were completed, including medication self-administration and instruction on resident needs.
85d - Trash Receptacles: On 10/5/20, no trash can was present in the 2nd floor common bathroom adjacent to the Covid-19 quarantine area, violating the requirement for covered trash receptacles.
141a - Medical Evaluation: Resident #1's initial medical evaluation was completed before admission date, not within required timeframe.
141b1 - Annual Medical Evaluation: Resident #2's most recent medical evaluation was conducted over a year ago with no documentation allowing postponement due to COVID-19 emergency.
221c - Post Activity Calendar: The home did not have a current weekly activity calendar posted in a public and conspicuous place; the posted calendar was dated August 2020.
224a - Preadmission Screen Form: Resident #1's preadmission screening form was completed after admission date, violating the requirement for completion within 30 days prior to admission.
227i - Support Plan Accessible: Resident support plans are stored in a locked medication room not accessible to all direct care staff, limiting access to required support plans.
Report Facts
Residents Served: 68
Current Hospice Residents: 8
Residents 60 Years or Older: 67
Residents with Mental Illness: 7
Residents with Intellectual Disability: 1
Residents with Mobility Need: 25
Residents Receiving Supplemental Security Income: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Barone | Lead Inspector | Lead inspector during the 10/05/2020 and 10/06/2020 inspection visits |
| Scott Klein | Department Representative | Department representative present during the 10/05/2020 and 10/06/2020 inspection visits |
| Suzy Quinn | Lead Reviewer | Lead reviewer for plan of correction submissions and on-site verification |
| Janet Torregrosso | Administrator | Facility administrator listed in the report |
Inspection Report — Oct 5, 2020
Original Licensing
Date: Oct 5, 2020
Visit Reason
The inspection was conducted as a licensing inspection for Norbert Residential Care Facility to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall and a regular license was issued. Several deficiencies were identified related to telephone access, training records, trash receptacles, medical evaluations, activity calendar posting, preadmission screening, and support plan accessibility, all with plans of correction implemented or directed.
Citations (8)
42e Telephone Access: Residents did not have access to a telephone in the home to make calls in privacy. The home implemented a private call room with a landline phone and trained staff and residents on the new process.
65i Training Record: The home's record of direct care staff training for 2019 did not indicate the dates certain trainings were completed, including medication self-administration and instruction on meeting resident needs.
85d Trash Receptacles: On 10/5/20, no trash can was present in the 2nd floor common bathroom adjacent to the COVID-19 quarantine area, a repeat violation from 10/22/2019.
141a Medical Evaluation: Resident #1's initial medical evaluation was completed before admission date, not within required timeframe.
141b1 Annual Medical Evaluation: Resident #2's most recent medical evaluation was conducted on 6/10/19 with no documentation allowing postponement due to COVID-19 emergency suspension.
221c Post Activity Calendar: The home did not have a current weekly activity calendar posted in a public and conspicuous place; the posted calendar was dated August 2020.
224a Preadmission Screen Form: Resident #1 was admitted on 6/4/20 but the preadmission screening form was completed on 3/27/20, a repeat violation.
227i Support Plan Accessible: Resident support plans were stored in a locked nurse's office accessed via keypad not available to all direct care staff, limiting access to support plans.
Report Facts
Residents Served: 68
Current Hospice Residents: 8
Residents 60 Years or Older: 67
Residents Diagnosed with Mental Illness: 7
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Torregrosso | Administrator | Named as facility administrator |
| Barbara Barone | Lead Inspector | Lead inspector for the licensing inspection |
| Scott Klein | Inspector | Inspector for the licensing inspection |
| Jamie L. Buchenauer | Deputy Secretary | Signed licensing letter and certificate |
Inspection Report — Sep 23, 2020
Follow-Up
Date: Sep 23, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. The follow-up addressed a repeat violation related to additional resident assessments, specifically for Resident #1 who is a fall risk with multiple falls.
Citations (1)
225c - Additional Assessment: Resident #1's most recent assessment was completed on 8/21/20; however, the previous assessment was completed on 6/14/19. The plan of correction included updating the RASP, initiating hourly checks, scheduling doctor visits, and implementing safety equipment and audits.
Report Facts
Residents Served: 69
Current Hospice Residents: 7
Resident Falls: 15
Monthly Audits: 3
Inspection Report — Oct 22, 2019
Renewal
Date: Oct 22, 2019
Visit Reason
The inspection was conducted as a renewal inspection with complaint and incident reasons, including multiple visits in 2019 to assess compliance with Personal Care Home regulations.
Complaint Details
The inspection was complaint-related with substantiated findings of resident abuse, medication errors, and failure to follow emergency medical plans.
Findings
The facility was found to have multiple violations related to resident abuse, medication administration, emergency medical plan, staffing, sanitary conditions, and documentation. Plans of correction were partially implemented with inadequate progress noted on several issues.
Citations (25)
15a - Resident Abuse Report: The home failed to immediately report suspected abuse when a resident was thrown to the floor and injured on 7/10/19.
42b - Abuse: Staff failed to prevent resident bruising when assisting with dressing on 7/10/19.
141a - Medical Evaluation Information: Resident #2's initial medical evaluation did not include medical diagnoses and lacked required documentation.
143a - Emergency Medical Plan: The home failed to follow its emergency medical plan after a resident fell and sustained fractures on 7/14/19.
183d - Prescription Current: Medications for resident #2 were discontinued but remained in the home on 7/23/19.
184a - Labeling OTC/CAM: Medication labels did not include proper pharmacy information or instructions for residents #2 and #3.
185a - Implement Storage Procedures: Resident #2's glucometer was not calibrated correctly and resident #4's blood glucose reading was inconsistent on 8/20/19.
187d - Follow Prescriber's Orders: Resident #2 was administered incorrect insulin units on 7/18/19 and medication administration was not properly documented on 8/26/19.
224a - Preadmission Screen Form: Resident #2's preadmission screening lacked a determination of needs on 5/28/19.
57c - 2 Hours/Day: The home failed to provide the minimum required personal care service hours for residents with mobility needs on 7/28/19, 8/19/19, and 8/20/19.
57d - Waking Hours: The home did not provide the minimum required direct care staffing hours during waking hours on 7/28/19, 8/19/19, and 8/20/19.
60a - Staff/Support Plan: Staffing was inadequate for night shift and emergency evacuation; some residents required assistance not met by staffing.
60c - Housekeeping/Maintenance: Residents were not served meals timely; housekeeping and maintenance needs were unmet including meal service delays and missing furniture.
85a - Sanitary Conditions: A pungent odor of urine was present on the 2nd floor on multiple dates.
85d - Trash Receptacles: An uncovered trash receptacle with strong odor was found in the shower room on 10/22/19.
92 - Windows: Multiple windows lacked screens and were in disrepair on 10/22/19.
95 - Furniture and Equipment: The 4th drawer of resident #2's dresser was missing on 10/22/19.
102i - Soap Dispenser: An unlabeled, used bar of soap was found in a common bathroom on 10/22/19.
103d - Storing Food Off Floor: Water containers were stored on the floor in closets on 10/22/19.
161d - Dietary Needs: Resident #3's diet was not properly followed; served food was not appropriate on 10/22/19.
183b - Meds and Syringes Locked: Medication packets and ointments were unlocked and accessible on 10/22/19.
184b - Resident's Meds Labeled: Medications were stored unlabeled and improperly in resident #5's room on 10/22/19.
225c - Additional Assessment: Resident #1's assessment lacked hearing needs and diagnoses on 7/19/19.
227g - Support Plan Signatures: Staff did not sign resident #5 and #7 support plans as required.
251b - Record Entries Legible: Resident #5's record had white-out over birth date and resident #7's record had white-out over room rate and amount.
Report Facts
Residents Served: 74
Resident Support Staff: 0
Total Daily Staff: 103
Waking Staff: 77
Resident Support Staff: 0
Total Daily Staff: 128
Waking Staff: 96
Residents Served: 88
Resident Support Staff: 0
Total Daily Staff: 118
Waking Staff: 89
Residents Served: 83
Current Residents Hospice: 11
Fine Amount: 370
Fine Amount: 370
Fine Amount: 222
Fine Amount: 222
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Torregrosso | Administrator | Named in multiple findings and plans of correction |
| Hal K. Waldman | President | Named in licensing and enforcement correspondence |
| Kevin Hancock | Deputy Secretary | Signed enforcement letter |
| Shivani Patel | Enforcement Manager | Named in enforcement letter |
Inspection Report — Jun 14, 2019
Complaint Investigation
Date: Jun 14, 2019
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Norbert Residential Care Facility on June 14, 2019.
Complaint Details
The visit was triggered by a complaint and incident. The violation involved unauthorized entry and medication administration failures. The violation was repeated from a prior inspection dated 4/26/19.
Findings
The inspection found a violation of 55 Pa. Code Ch. 2600 related to failure to follow prescriber's orders. Specifically, 11 residents missed their scheduled AM dose of narcotics due to two masked intruders entering the home and the door not being properly secured.
Citations (1)
55 Pa. Code 2800.187d. The home failed to follow the directions of the prescriber when 11 residents missed their scheduled AM dose of narcotics after two masked intruders entered the home and the door was not properly locked.
Report Facts
Residents served: 81
Residents missing scheduled narcotics dose: 11
Staff total daily: 133
Staff waking: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Torregrosso | Administrator | Signed plan of correction and named as administrator |
| Suzy Quinn | Human Services Licensing Supervisor | Conducted inspection and signed cover letter |
| Joe Eveges | Department representative present during inspection |
Inspection Report — Feb 11, 2019
Complaint Investigation
Date: Feb 11, 2019
Visit Reason
The inspection was conducted due to a complaint and incident reported at Norbert Residential Care Facility.
Complaint Details
The complaint involved an allegation of staff abuse reported by resident #1. The allegation was substantiated as the facility failed to report the incident timely to the appropriate authorities.
Findings
The facility was found to have violations related to failure to report suspected abuse timely and comply with reporting requirements under the Older Adults Protective Services Act. A plan of correction was implemented including staff training and monitoring of reportable incidents.
Citations (3)
55 Pa.Code §2600.15(a) - The home failed to immediately report suspected abuse of a resident in accordance with the Older Adults Protective Services Act and comply with reporting requirements regarding restrictions on staff persons.
Description of violation - On 1/24/19, resident #1 made direct care staff aware of an allegation that staff person B touched the resident in the chest and vaginal area while providing care, but the allegation was not reported to the Area Agency on Aging until 1/25/19 at approximately 5:00 p.m.
55 Pa.Code §2600.16(c) - The home failed to report the incident or condition to the Department's personal care home complaint hotline within 24 hours as required by regulation.
Report Facts
Number of Residents Served: 88
Number of Current Hospice Residents: 9
Number of Hospice Residents in past year: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named in plan of correction and signature on violation report |
| Desmond Grace | Inspection representative involved in the complaint investigation | |
| Lauren Spagna | Inspection representative involved in the complaint investigation |
Inspection Report — Jan 8, 2019
Complaint Investigation
Date: Jan 8, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation at Norbert Residential Care Facility on January 8, 2019.
Complaint Details
The inspection was triggered by complaints and incidents involving resident abuse, neglect, and financial exploitation. The violations were substantiated as detailed in the violation report.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including misuse of resident funds, resident abuse and neglect, unsafe environment, and failure to follow prescriber’s orders. Plans of correction were partially implemented with inadequate progress.
Citations (5)
Regulation 2600.20(b)(4) - Resident funds were misappropriated when staff accepted, endorsed, and deposited resident checks into a personal bank account.
Regulation 2600.42(b) - A resident was physically injured when staff transported her improperly, causing a head injury requiring emergency care.
Regulation 2600.42(b) - A resident was verbally and physically abused by staff who pulled his leg and caused skin tears.
Regulation 2600.100(a) - The exterior fence was unsecured and loose, causing a resident to fall and sustain fractured vertebrae and bruises.
Regulation 2600.187(d) - Staff failed to follow prescriber’s orders by not turning on oxygen flow for a resident prescribed continuous oxygen via nasal cannula.
Report Facts
Number of Residents Present: 89
Number of Deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as legal entity representative and involved in plans of correction |
Inspection Report — Dec 3, 2018
Routine
Date: Dec 3, 2018
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Norbert Residential Care Facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Oct 30, 2018
Renewal
Date: Oct 30, 2018
Visit Reason
The document is a renewal license issued to Norbert Residential Care Facility to operate as a Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and outlines the regulatory requirement for a future inspection.
Report Facts
Inspection Report — Oct 29, 2018
Complaint Investigation
Date: Oct 29, 2018
Visit Reason
The inspection was conducted as a complaint investigation of Norbert Residential Care Facility on October 29, 2018.
Complaint Details
The inspection was triggered by a complaint. Specific violations involved failure to respond to call bell and improper medication administration.
Findings
The inspection found violations of 55 Pa. Code Chapter 2600 related to resident assistance with activities of daily living and medication administration. The facility failed to respond timely to a resident's call bell and improperly left medication unattended.
Citations (2)
55 Pa.Code §2600.23(a) - The home failed to respond promptly to a resident's call bell for toileting assistance, resulting in the resident urinating in bed and waiting for assistance.
55 Pa.Code §2600.182(c) - Medication administration was deficient as two white tablets were left in a clear plastic cup on the resident's bedside table, allowing the resident to take medication unsupervised.
Report Facts
Number of Residents Served: 95
Number of Current Hospice Residents: 12
Number of Hospice Residents in past year: 42
Number of Residents 60 Years or Older: 34
Number of Residents with Mental Illness: 9
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Needs: 37
Number of Residents with Physical Disability: 1
Number of Residents Receiving Supplemental Security Income: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named in plan of correction for violations |
Inspection Report — Sep 13, 2018
Complaint Investigation
Date: Sep 13, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an allegation of abuse involving resident #1.
Complaint Details
The complaint investigation was triggered by an allegation of abuse involving resident #1, who sustained a black eye on 8/30/18. The home completed an investigation but did not submit an incident report to the Department as required.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to report an incident timely, unsafe wheelchair conditions, unsanitary conditions, and incomplete resident assessments. Plans of correction were partially implemented with adequate progress noted.
Citations (4)
55 Pa.Code 2600.16(c) - The home failed to report an incident involving resident #1's black eye to the Department within 24 hours as required.
55 Pa.Code 2600.81(b) - The left vinyl armrest of resident #1's wheelchair had multiple cracks exposing fabric, posing a skin tear hazard.
55 Pa.Code 2600.85(a) - In room 317, a urinal filled with approximately 2 inches of urine was found on resident #2's bedside table.
55 Pa.Code 2600.225(c) - Resident #1's assessment dated 1/10/18 did not include diagnoses of shortness of breath, psychosis, and dry eyes as indicated on the medical evaluation.
Report Facts
Number of Residents Served: 91
Number of Current Hospice Residents: 14
Number of Hospice Residents in past year: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as the legal entity representative and responsible for plan of correction approval and review. |
| Lisa Flinner-Alman | Department Representative | On-site inspector present during the complaint investigation. |
| Scott Klein | Department Representative | On-site inspector present during the complaint investigation. |
Inspection Report — Aug 8, 2018
Complaint Investigation
Date: Aug 8, 2018
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving alleged resident abuse and mistreatment.
Complaint Details
The complaint investigation was substantiated based on witness interviews and observations of staff person A's abusive behavior toward residents #1 and #2.
Findings
The investigation found that staff person A used profanities, pushed resident #1, and smacked the resident in the head. Resident #1 became agitated and yelled out in pain after being struck. Staff person A also used profanities in front of other staff and residents and pushed resident #2 out of the dining room.
Citations (1)
55 Pa.Code §2600.42(b) - A resident may not be neglected, intimidated, physically or verbally abused, mistreated, subjected to corporal punishment or disciplined in any way. Staff person A pushed resident #1 out of an elevator, used profanities, smacked the resident in the head, and pushed resident #2 out of the dining room.
Report Facts
Number of Residents Served: 92
Number of Current Hospice Residents: 10
Number of Residents who are 60 Years of Age or Older: 91
Number of Residents with Mental Illness: 10
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 35
Number of Residents Receiving Supplemental Security Income: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as the facility administrator and legal entity representative who signed the plan of correction |
| Josh Hoover | Department representative who conducted the on-site inspection |
Inspection Report — Jul 18, 2018
Renewal
Date: Jul 18, 2018
Visit Reason
The inspection was conducted as a partial type triggered by renewal and complaint reasons on July 18 and 19, 2018, at Norbert Residential Care Facility.
Findings
Multiple violations related to fire drills and medication equipment were found, including failure to conduct fire drills during sleeping hours as required and improper glucometer settings. Plans of correction were submitted and partially implemented.
Citations (4)
55 Pa.Code §2600.132(e) - A fire drill shall be held during sleeping hours once every 6 months. The last two sleeping hour fire drills were conducted on 7/31/17 and 4/27/18, not meeting the required schedule.
55 Pa.Code §2600.132(g) - Fire drills shall be held on different days and times, not routinely at low attendance times. The 4/27/18 drill had 9 staff participating but only 4 staff are routinely scheduled for the night shift.
55 Pa.Code §2600.132(h) - Residents shall evacuate to a designated meeting place during fire drills. Interviews indicated some residents remained in rooms with pillows placed outside doors and insufficient staff to assist evacuation.
55 Pa.Code §2600.185(a) - The home shall develop procedures for safe storage and use of medications and equipment. On 7/18/18, the glucometer for resident #2 was not set to the correct date and time.
Report Facts
Number of Residents Served: 96
Number of Current Hospice Residents: 15
Number of Hospice Residents in past year: 37
Staff Participating in Fire Drill: 9
Staff Routinely Scheduled for Night Shift: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as legal entity representative and signer of plans of correction. |
| Cindy Mulick | Department representative present during inspection. | |
| Jason Williams | Department representative present during inspection. | |
| Lori Gillette | Department representative present during inspection. |
Inspection Report — May 10, 2018
Routine
Date: May 10, 2018
Visit Reason
The Department's Bureau of Human Services Licensing conducted an inspection of Norbert Residential Care Facility on May 10, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Williams | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Feb 6, 2018
Complaint Investigation
Date: Feb 6, 2018
Visit Reason
The inspection was conducted due to complaints and incidents reported at Norbert Residential Care Facility on February 6, 2018 and March 13, 2018.
Complaint Details
The inspection was complaint-driven, triggered by reports of resident abuse and neglect. The home failed to report suspected abuse and adequately protect residents from harm.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including failure to report suspected abuse, neglect and mistreatment of residents, inadequate supervision to prevent abuse, and insufficient support plans for residents with aggressive and sexually abusive behavior.
Citations (5)
Regulation 2600.15(a): The home failed to immediately report suspected abuse of a resident involving exposure of genitals and attempted inappropriate contact between residents.
Regulation 2600.16(c): The home failed to report an incident or condition to the Department's personal care home regional office within 24 hours as required.
Regulation 2600.42(b): A resident was neglected and subjected to physical and verbal abuse, including exposure of genitals and aggressive behavior, and the home failed to supervise to prevent abuse of other residents.
Regulation 2600.225(c): The resident's assessment did not include required additional assessments or address the need for extensive supervision for aggressive and sexually abusive behavior.
Regulation 2600.227(c): The support plan was not revised to address the resident's need for extensive supervision and did not include special training for staff regarding the resident's status as a registered Megan's law offender.
Report Facts
Number of Residents Served: 88
Number of Current Hospice Residents: 14
Number of Hospice Residents in past year: 52
Number of Residents who are 80 Years or Older: 86
Number of Residents with Mental Illness: 11
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 34
Number of Residents with Supplemental Security Income: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named in plan of correction and signature on violation reports |
Inspection Report — Jan 19, 2018
Complaint Investigation
Date: Jan 19, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Norbert Residential Care Facility to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven. Specific complaints involved inadequate personal care service hours and incomplete resident documentation. The violations were substantiated as noted in the violation report.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including insufficient personal care service hours, incomplete preadmission screening documentation, and outdated resident support plans. Plans of correction were submitted addressing these issues with partial implementation progress noted.
Citations (3)
55 Pa.Code §2600.57(d) requires at least 75% of personal care service hours to be available during waking hours. The facility provided only 98.75 hours of direct care staffing instead of the required 101.25 hours on 1/6/18.
55 Pa.Code §2600.224(a) requires preadmission screening documentation within 30 days prior to admission. The screening for resident #1 admitted 2017 is undated and incomplete.
55 Pa.Code §2600.227(d) requires home health service documentation in resident support plans. Resident #1's support plan dated 9/11/17 is not updated to reflect services provided.
Report Facts
Number of Residents Served: 98
Personal Care Service Hours Required: 101.25
Personal Care Service Hours Provided: 98.75
Residents with Mobility Needs: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as legal entity representative and responsible for plan of correction. |
| Matt Rahuba | Department representative on-site during inspection. |
Notice — Oct 26, 2017
Date: Oct 26, 2017
Visit Reason
This document serves as a renewal notification and license issuance for Norbert Residential Care Facility to operate as a Personal Care Home, including a reminder of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative letter confirming license renewal and outlining inspection requirements.
Report Facts
Inspection Report — Aug 31, 2017
Routine
Date: Aug 31, 2017
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of Norbert Residential Care Facility on August 31, 2017.
Findings
No regulatory violations were identified as a result of this inspection.
Inspection Report — Aug 21, 2017
Routine
Date: Aug 21, 2017
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of Norbert Residential Care Facility on August 21, 2017.
Findings
No regulatory violations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Sutherland | Acting Regional Licensing Director | Signed the inspection report letter. |
Inspection Report — Jul 12, 2017
Renewal
Date: Jul 12, 2017
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Norbert Residential Care Facility on July 12 and 13, 2017.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care home regulations were found, including missing influenza information posting, incomplete staff training, sanitation issues, fire safety drill deficiencies, and medication labeling errors. Plans of correction were submitted and partially or fully implemented by March 6, 2018.
Citations (11)
55 Pa.Code 2600.18 - The facility did not have the required influenza information posted in a public place on 7/12/17.
55 Pa.Code 2600.65(f) - Direct care staff member B did not receive required 2016 training on medication self-administration, dementia care, personal care needs, and care for residents with mental illness or intellectual disability.
55 Pa.Code 2600.66(b) - The 2017 staff training plan did not include scheduled trainings for all required topics as of 7/12/17.
55 Pa.Code 2600.85(a) - No cloth or paper towels or other hand-drying means were present in resident #1's bathroom on 7/13/17 at 1:51 p.m.
55 Pa.Code 2600.85(d) - Trash can lid was missing in the common men's bathroom on 7/12/17, and the trash was approximately half full.
55 Pa.Code 2600.101(j)(7) - Resident #2's bedside lamp was located approximately 5 feet from the bed and was not accessible at bedside on 7/13/17.
55 Pa.Code 2600.107(c) - The home did not maintain an adequate emergency supply of drinking water; only 59 gallons were available on 7/13/17, less than the required 3-day supply.
55 Pa.Code 2600.132(e) - The facility did not conduct a fire drill during sleeping hours within the past 6 months prior to 12/20/16.
55 Pa.Code 2600.144(c)(1)(D) - A 2-gallon trash can containing approximately 30 cigarette butts was present in the home's designated smoking area and was used as a receptacle for smoking materials on 7/12/17.
55 Pa.Code 2600.184(a) - Resident #45's pharmacy label was incorrect on 7/13/17; it indicated pantoprazole 40mg once daily but the resident was prescribed 1 tablet twice daily.
55 Pa.Code 2600.187(a) - Resident #42's medication administration record did not include initials of staff administering evening doses from 7/1/17 through 7/12/17.
Report Facts
Number of Residents Served: 95
Number of Current Hospice Residents: 13
Number of Hospice Residents in past year: 35
Number of Residents 60 Years or Older: 92
Number of Residents with Mental Illness: 12
Number of Residents with Intellectual Disability: 2
Number of Residents with Mobility Need: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Signed plans of correction and legal entity representative for violations |
Inspection Report — May 1, 2017
Complaint Investigation
Date: May 1, 2017
Visit Reason
The inspection was conducted as a complaint investigation at Norbert Residential Care Facility on May 1, 2017.
Complaint Details
The visit was complaint-driven. The complaint involved an unreported physical assault incident on 4/18/2017. The incident was investigated by police but was not reported to the Department as required.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including failure to report an incident of physical assault to the Department. A plan of correction was submitted addressing staff training and reporting procedures.
Citations (1)
Regulation 55 Pa.Code §2600 16(c) requires the home to report incidents or conditions to the Department within 24 hours. The facility failed to report a physical assault incident involving resident #3 that occurred on 4/18/2017.
Report Facts
Number of Residents Served: 95
Total Daily Staff: 130
Walking Staff: 98
Number of Current Hospice Residents: 10
Number of Hospice Residents in past year: 27
Number of Residents 60 Years or Older: 93
Number of Residents with Mental Illness: 14
Number of Residents with Intellectual Disability: 2
Number of Residents with Mobility Needs: 35
Number of Residents with Physical Disability: 0
Date of Incident: Apr 18, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as Administrator and legal entity representative who signed the plan of correction. |
| Jason Williams | Human Services Licensing Supervisor | Signed the cover letter transmitting the inspection results. |
Inspection Report — Feb 1, 2017
Complaint Investigation
Date: Feb 1, 2017
Visit Reason
The inspection was conducted as a complaint investigation at Norbert Residential Care Facility to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. Specific substantiation status is not stated in the report.
Findings
Multiple violations were found related to insufficient personal care service hours during waking hours, incomplete resident assessments especially regarding fall risk, lack of fall risk precautions in support plans, and use of non-approved medical evaluation forms. Plans of correction were partially implemented with adequate progress noted.
Citations (5)
Regulation 55 Pa.Code §2600.57(d): The home failed to provide the required minimum personal care service hours for residents with mobility needs during waking hours, providing only 85.25 hours instead of the required 93.75 hours.
Regulation 55 Pa.Code 2600.225(a): Resident #1's initial assessment did not include fall risk factors despite multiple documented falls and observations of the resident on the floor.
Regulation 55 Pa.Code 2600.225(c): Resident #2's assessment did not address fall risk despite several documented falls and injuries, including a fall resulting in a head injury requiring hospital transfer.
Regulation 55 Pa.Code 2600.227(d): Resident #1 and #2's support plans lacked fall risk precautions and did not reflect documented falls and gait issues.
Regulation 55 Pa.Code 2600.251(c): Medical evaluations for Residents #1, #2, and #3 were not completed on Department-approved standardized forms.
Report Facts
Number of Residents Served: 91
Number of Residents with Mobility Needs: 34
Required Personal Care Hours: 93.75
Provided Personal Care Hours: 85.25
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named in multiple plans of correction and signature on violation report pages |
| Courtney Barry | Department representative conducting inspection | |
| Cindy Mulick | Department representative conducting inspection |
Inspection Report — Oct 31, 2016
Routine
Date: Oct 31, 2016
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of Norbert Residential Care Facility on October 31, 2016.
Findings
No regulatory violations were identified as a result of this inspection.
Notice — Oct 28, 2016
Date: Oct 28, 2016
Visit Reason
This document serves as a renewal notification and license issuance for Norbert Residential Care Facility to operate as a Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.
Findings
The Department of Human Services confirms receipt of the renewal application and issues a regular license. It advises that an annual onsite inspection will be conducted within the next twelve months to ensure compliance.
Report Facts
Inspection Report — Aug 16, 2016
Annual Inspection
Date: Aug 16, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on August 16 and 17, 2016, including renewal and complaint reasons.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care homes were found, including deficiencies in staff training, record keeping, safety, sanitation, and emergency preparedness. Plans of correction were submitted and partially implemented as of December 8, 2016.
Citations (10)
55 Pa.Code 2600.85(e) - Direct care staff persons had insufficient annual training hours; one staff had only 3 hours instead of 12 required.
55 Pa.Code 2600.85(i) - Training records lacked details on length of courses and certificates received for staff person B.
55 Pa.Code 2600.82(c) - Poisonous materials were unlocked and accessible in resident #134's room.
55 Pa.Code 2600.85(a) - Garbage can in shower room was overflowing and garbage was found on the patio floor outside the activities area.
55 Pa.Code 2600.85(e) - Trash outside the home was uncovered and overflowing, including two blue mattresses and a wooden dresser on the dumpster.
55 Pa.Code 2600.93(a) - Stairwell railings on B wing 2nd and 3rd floors were unsecured with rust and connected to cracked concrete.
55 Pa.Code 2600.123(b) - Emergency preparedness plans were not posted in a conspicuous and public place in the home.
55 Pa.Code 2600.125(a) - Combustible materials were stored near heat sources; an operator's manual was stored on top of boiler #2 and a cardboard box was stored 28 inches from the boiler.
55 Pa.Code 2600.141(a)(2) - Medical evaluation for resident #2 lacked height and weight information.
55 Pa.Code 2600.224(a) - Preadmission screening forms for residents #1, #2, and #3 were incomplete and did not indicate if the home could meet residents' needs.
Report Facts
Number of Residents Served: 88
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 34
Staff Training Hours: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as legal entity representative and responsible for plans of correction |
Inspection Report — May 19, 2016
Complaint Investigation
Date: May 19, 2016
Visit Reason
The inspection was conducted as a licensing inspection triggered by a complaint and incident investigation at Norbert Residential Care Facility on May 19 and May 20, 2016.
Complaint Details
The inspection was complaint-related, triggered by allegations of abuse involving staff and concerns about care and medication administration. The complaint was substantiated as violations were found.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to develop a plan of supervision for alleged abuse, insufficient direct care staffing hours, medication administration and storage issues, and inaccurate service descriptions. Plans of correction were partially implemented with adequate progress noted.
Citations (9)
55 Pa.Code 2600.15(b): The home failed to immediately develop and implement a plan of supervision or suspend staff involved in an alleged abuse incident reported on 5-19-16.
55 Pa.Code 2600.57(c): On 4-15-16, the facility provided only 119.5 hours of direct care staffing instead of the required 120 hours for 31 residents with mobility needs.
55 Pa.Code 2600.57(d): On 3-26-16 and 4-15-16, the facility failed to provide at least 75% of personal care service hours during waking hours, providing only 89.5 and 80.5 hours respectively.
55 Pa.Code 2600.181(c): Resident #2 was not assessed by a qualified professional for ability to self-administer medications and medication reminders despite having a wound requiring treatment.
55 Pa.Code 2600.183(b): On 5-20-16, unlocked and accessible prescription medications and syringes were found in resident #2's room.
55 Pa.Code 2600.183(f): Staff disposed of 11 doses of Tramadol-50mg tablets by flushing them down the drain on 5-4-16, contrary to proper disposal regulations.
55 Pa.Code 2600.187(a): Resident #3's medication administration record lacked required information including prescribed dosage, route, frequency, and administration times.
55 Pa.Code 2600.187(b): Resident #3's medication was not initialed by staff on multiple occasions in April 2016 as required.
55 Pa.Code 2600.223(a): The home did not accurately describe services and activities, failing to indicate it does not serve residents with stage III or IV wounds.
Report Facts
Number of Residents Served: 87
Number of Residents with Mobility Needs: 31
Direct Care Staffing Hours Required: 120
Direct Care Staffing Hours Provided: 119.5
Direct Care Staffing Hours Provided: 89.5
Direct Care Staffing Hours Provided: 80.5
Number of Current Hospice Residents: 9
Number of Hospice Residents in Past Year: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Deems | Administrator | Named as legal entity representative and signer of plans of correction |
Inspection Report — Jan 19, 2016
Complaint Investigation
Date: Jan 19, 2016
Visit Reason
The inspection was conducted as a complaint and incident investigation at Norbert Residential Care Facility over multiple dates in January 2016.
Complaint Details
The inspection was complaint-driven and incident-related, investigating allegations of abuse and other regulatory violations. Specific abuse allegations were not reported to the Department timely as required.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to report suspected abuse, incomplete criminal background checks, inadequate fire drill documentation, incomplete medical evaluations, and unqualified medication administration by staff.
Citations (8)
Regulation 55 Pa.Code 2600.15(a): The home failed to immediately report suspected abuse of a resident witnessed by staff on 1/27/16.
Regulation 55 Pa.Code 2600.16(c): The home did not report an incident involving a resident injury and staff failure to report to the Department within 24 hours.
Regulation 55 Pa.Code 2600.51: The home hired a direct care staff person without completing a criminal background check.
Regulation 55 Pa.Code 2600.132(c): Fire drill records lacked specific times of day for drills conducted on 8/31/15, 9/29/15, and 10/30/15.
Regulation 55 Pa.Code 2600.132(d): The home exceeded the safe evacuation time during fire drills and failed to evacuate all residents present on 1/27/16.
Regulation 55 Pa.Code 2600.141(a)(1): Resident #1's initial medical evaluation was incomplete, missing height, weight, and second page with special diet and medication details.
Regulation 55 Pa.Code 2600.141(b)(1): Resident #4 lacked an annual in-person medical evaluation since 8/4/14.
Regulation 55 Pa.Code 2600.190(a): Direct care staff person F did not complete the required Department-approved annual medication administration practicum and administered medications improperly on multiple dates.
Report Facts
Number of Residents Served: 95
Number of Current Hospice Residents: 14
Number of Hospice Residents in Past Year: 30
Residents Present During Fire Drill: 92
Residents Evacuated During Fire Drill: 85
Residents Age 60 or Older: 93
Residents with Mental Illness: 2
Residents with Mobility Need: 32
Residents Receiving Supplemental Security Income: 1
Notice — February 8, 2017
Date: February 8, 2017
Visit Reason
This document serves to notify Norbert Residential Care Facility of the granted waiver for specific Pennsylvania Code requirements related to admission, resident medical evaluation, and preadmission screening.
Findings
The waiver is granted under specified conditions and will be reviewed annually during the facility's annual inspection to ensure compliance. Failure to comply may result in termination of the waiver or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Rowe | Director | Signed the waiver approval letter. |
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