Norlite Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to provide food in a manner that was at palatable (preferable) temperatures for four Residents (#4, #5, #6, and #7) of five residents reviewed for palatability of meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary equipment was readily available to provide care for two dependent Residents (#62 and #46) out of 18 residents reviewed for quality of life. This deficient practice resulted in emotional distress, feelings of frustration, social isolation, and physical discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. This deficient practice resulted in unmet care needs and the potential for serious safety issues for all 82 residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat five Residents (#10, #30, #35, #37, & #56) with a dignified dining experience out of 18 residents reviewed for dignity. This deficient practice resulted in a lack of personal dignity and feelings of embarrassment based on the reasonable person.

Inspectors wroteBased on interview and record review, the facility failed to provide advanced written notification of a room change for 3 Confidential Residents (CR's) of 14 residents during the resident group interview and one Resident (#6) of one resident reviewed for room changes.

Inspectors wroteBased on interview and record review, the facility failed to maintain a homelike environment by ensuring resident room temperatures were maintained within the acceptable parameters for two Confidential Residents (CR's) out of 14 residents from a resident group interview and 2 Residents (#39 & #62) of 18 residents reviewed for environmental concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate food temperatures and palatability for nine Confidential Residents (CR) of fourteen residents reviewed for food satisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 1/27/2026 at 3:30 PM, three boxes of single serve items, including cups and lids, were observed sitting on the storage room floor. The boxes were opened with some of the contents used. When asked about deliveries, Dietary Manager (DM) T stated that the last delivery came in the day before. According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; [...]

Inspectors wroteThis citation pertains to intake #2687526. Based on interviews and record review the facility failed to protect the resident's right to be free from physical abuse by a resident for one Resident (#90) of two residents reviewed for abuse resulting in R82 grabbing R90's head, and based on the reasonable person concept would cause feelings of pain, fear and intimidation for Resident #90.

Inspectors wroteThis citation pertains to intake# 2687526Based on interviews and record review, the facility failed to fully implement its Abuse Program Policy and Procedure and immediately identify and thoroughly investigate incidents of resident to resident abuse for 2 Residents (Residents #82 & #90) from 18 residents reviewed for abuse and based on the reasonable person concept would cause feelings of pain, fear and intimidation for Residents #90, and the potential for continued resident abuse to go unreported and/or undetected.

Inspectors wroteThis citation pertains to intake #2687526. Based on interviews and record review the facility failed to implement their policy and procedure for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and as a result of the facility's failure to implement the facility Abuse Policy and ensure resident safety, resulted in R82's physical abuse to continue and placed all residents at risk for serious injury, physical and psychosocial harm, and impairment. Review of an Anonymous Complaint to the State Agency dated 12/08/2025 1:58 PM read in part: (R82) grabbed (R90's) head aggressively, (facility staff name omitted) and (facility staff name omitted) intervened between the two. Both nurses called (Director of Nursing-DON) immediately after reporting the incident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent wandering residents entering private resident rooms resulting in feelings of frustration for five Confidential Residents (CR's) out of 14 residents in a confidential group interview and one Resident (#10) out of 18 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain appropriate standards of infection control practices to prevent the spread of pneumonia for one Resident (R36) of one Resident reviewed for infection control practices. This deficient practice resulted in the potential for continued spread of pneumonia to other residents residing within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 76 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience in their Dining Room (DR) by standing over seated residents while assisting with feeding and failing to serve all residents at the same table together. This deficient practice had the potential to affect all residents dining in the main dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one medication cart remained locked when unattended of four medication carts reviewed, and failed to discard two expired glucose meter control solutions of six control solutions reviewed. This deficient practice resulted in the potential for misappropriation of medications for the nine residents on the 500 unit, and the potential for inaccurate blood glucose readings for six residents receiving blood glucose testing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate nutritional assessment, and interventions for one Resident (#63) of one resident reviewed for significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure a change in condition was assessed and monitored by the attending physician for one Resident (#22) of 19 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for 2 Residents (#25 and #41) of 5 Residents reviewed for nutritional issues. This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications.

Inspectors wroteBased on interview and record review, the facility failed to assess and/or prevent or a significant weight loss for one Resident (R2), of three residents reviewed for nutrition. This deficient practice resulted in a significant weight loss of 12.9% within three weeks of admission to the facility for R2.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management as prescribed by the physician consistent with professional standards of practice for one Resident (R2), of three residents reviewed for pain management. This deficient practice resulted in the consistent late administration of prescribed pain medication and non-administration of available PRN (as needed) pain medication to address R2's pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a Resident-to-Resident physical abuse, resulting in minimal harm for one Resident (R38) of two residents reviewed for abuse. This deficient practice resulted in numerous bruising sites and persistent fear of further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure food contact surfaces were maintained in a clean and sanitary condition. 2. Failing to ensure expired food was discarded. 3. Failing to demonstrate proper testing of the sanitizing solution 4. Failing to maintain non-food contact surfaces in a clean manner. 5. Failing to label food in the walk in freezer which had been removed from its original packaging. 6. Failing to ensure the drain from the ice machine was not subject to back siphonage of contaminated water. 7. Failing to maintain two hand sinks in good repair 8. Failing to maintain walls and floors in a clean condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement interventions to address care needs for three Residents (R39 & R50) of 18 residents reviewed for care planning. This deficient practice resulted in lack of adequate care plans to ensure appropriate care was provided.

Inspectors wroteBased on interview and record review, the facility failed to update or revise care plan interventions in a timely manner for two Resident (#48 & #56) of eighteen residents reviewed for care plans. This deficient practice resulted in the potential for unmet care needs. Findings Include: Resident #56 (R56) Review of R56's electronic medical record (EMR) revealed initial admission to the facility on 3/3/22 with diagnoses including dementia and cognitive communication deficit. Review of R56's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Review of R56's EMR revealed nine falls occurred between the dates of 9/20/23 - 11/16/23 (9/20/23, 9/22/23, 9/27/23, 9/30/23, 10/1/23, 10/18/23, 10/19/23, 10/20/23, 11/16/23). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (R32) with missing hearing aids of two residents reviewed for assistive devices was assisted in making an appointment with a professional specializing in the provision of hearing assistive devices. This deficient practice resulted in the potential for impaired communication in social interactions and voiced frustration due to inability to adequately hear others when they are speaking.

Inspectors wroteBased on observation, interview, and record review, consistently monitor and assess effectiveness of behavioral interventions and provide behavioral health services for 1 resident (R10) of 2 residents reviewed for behaviors. This deficient practice resulted in continued severe outbursts of anger and mental distress and the potential for harm to self or others due to exhibited untreated behaviors.

Inspectors wroteBased on observation and record review, the facility failed to maintain a medication administration error rate of less than 5% based on two medication errors of 26 medication administration opportunities. This deficient practice resulted in a medication administration error rate of 7.7% and the potential for inaccurate dosage of medications.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor resident infections, as evidenced by, lack of a real-time resident surveillance log of all residents with symptoms of infections, lack of employee/resident infection comparisons, and lack of timely identification and analysis of infectious organism clusters. This deficient practice resulted in the potential for the spread of infectious organisms in the entire susceptible population of 74 residents.