Inspection Report
Census: 61
Capacity: 102
Deficiencies: 0
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
License Capacity: 102
Secured Dementia Care Unit Capacity: 26
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
Renewal
Census: 60
Capacity: 102
Deficiencies: 5
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 102
Residents Served: 60
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Capacity Revised: 26
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
Complaint Investigation
Census: 59
Capacity: 102
Deficiencies: 0
Mar 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation at Norbert Residential Care Facility on 03/20/2025.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 102
Residents Served: 59
Secured Dementia Care Unit Capacity: 17
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
Complaint Investigation
Census: 50
Capacity: 102
Deficiencies: 3
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.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
License capacity: 102
Residents served at inspection: 50
Secured Dementia Care Unit capacity: 7
Secured Dementia Care Unit revised capacity: 17
Total daily staff: 72
Waking staff: 54
Inspection Report
Complaint Investigation
Census: 54
Capacity: 102
Deficiencies: 1
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| Failure to complete additional assessments for a resident whose condition significantly declined, requiring increased hospice services and wound care. |
Report Facts
License Capacity: 102
Residents Served: 54
Secured Dementia Care Unit Capacity: 7
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
Original Licensing
Census: 48
Capacity: 102
Deficiencies: 0
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
License Capacity: 102
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
Complaint Investigation
Census: 58
Capacity: 102
Deficiencies: 3
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.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 102
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
Complaint Investigation
Census: 61
Capacity: 102
Deficiencies: 2
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.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 102
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
Renewal
Census: 72
Capacity: 102
Deficiencies: 12
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.
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.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit: Renewal, Complaint.
Deficiencies (12)
| Description |
|---|
| 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
License Capacity: 102
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
Capacity: 102
Deficiencies: 0
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
Maximum licensed capacity: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 102
Deficiencies: 0
Jun 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation at Norbert Residential Care Facility on 06/23/2021.
Findings
No regulatory citations or deficiencies were identified during this complaint investigation inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Report Facts
License Capacity: 102
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
Complaint Investigation
Census: 51
Capacity: 102
Deficiencies: 4
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.
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.
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.
Deficiencies (4)
| Description |
|---|
| 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
License capacity: 102
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
Renewal
Deficiencies: 0
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
Complaint Investigation
Census: 56
Capacity: 102
Deficiencies: 1
Apr 14, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Norbert Residential Care Facility.
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.
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.
Deficiencies (1)
| Description |
|---|
| 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
License Capacity: 102
Community Fee: 500
Inspection Report
Follow-Up
Census: 53
Capacity: 102
Deficiencies: 1
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| Resident #1 was verbally and physically abused by staff person A, who dragged the resident and used inappropriate language. |
Report Facts
Residents Served: 53
License Capacity: 102
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
Complaint Investigation
Census: 54
Capacity: 102
Deficiencies: 4
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.
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.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the partial, unannounced nature of the inspection.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 102
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 |
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