Norriton Square Nursing and Rehabilitation Center

Inspectors wroteBased on observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to care and maintenance of bedside commode in one of two nursing floors. (Second floor)

Inspectors wroteBased on reviews of the established meal delivery schedule, interviews with dietary staff, observations of the food and nutrition services on the nursing units and a review of the dietary staffing schedules for the kitchen, it was determined that the facility failed to employ sufficient staff to carry out the functions of the dietary services department.

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Resident R65). [...]

Inspectors wroteBased on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for one of four residents observed during medication administration observation, resulting in significant medication error (Residents R65). [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of 32 Residents reviewed (R44). Findings Include: [...]

Inspectors wroteBased on observation, clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to adhere to acceptable standards of nursing practice related to medication administration for one of four residents observed during medication administration (Resident R65).

Inspectors wroteBased reviews of policies and procedures, clinical record reviews, observations of care and services, interviews with residents, staff and family members, it was determined that for one of four residents reviewed for emotional behavior, sensory, communication and dignity, the facility failed to ensure a fully functioning hearing device was available and used according to audiology assessment and care planning. (Resident R86)A review of the facility policy titled consultant agreements and responsibilities revealed that the facility was responsible for making arrangements for care and services for the residents that the facility does not employ as staff through a qualified professional outside service. [...]

Inspectors wroteBased upon review of clinical records, interviews with staff and residents and reviews of policies and procedures, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow the physician's orders for daily weights for one of twenty-two residents reviewed. (Resident R35)Findings Include: Review of facility policy titled, Weights and Heights with a revision date of June February 1, 2023 states, Obtaining and Documenting Weight- 1.1.4 If the body weight is not as expected, re-weigh the patient. Resident R35 was admitted to the facility July 1, 2025 with the following diagnosis: [...]

Inspectors wroteBased on observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to medications found at bedside for one of twenty-two residents reviewed. (Resident R3) Findings Include: Review of facility policy titled, Medication Administration with a date of 2007 states, Policy- Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Further review of the Medication Administration policy revealed, Medication Administration. 4. Medications are administered at the time they are prepared. 5. [...]

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one Dialysis-Residents reviewed (Residents R9). Review of Resident 9's clinical records indicated that R9 was admitted in the facility on May 10, 2025, with Diagnoses including Dependence on Renal Dialysis (refers to the mandatory, long-term use of artificial filtration (hemodialysis or peritoneal dialysis) to replace lost kidney function). Review of physician order for R9, dated June 2, 2025, August 28, 2025, and January 16, 2026, revealed; Dialysis days: Tuesdays, Thursdays, and Saturdays. Time for Pick up: 5;30 a.m. [...]

Inspectors wroteBased on review of facility policies, clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure a resident was free from misappropriation related to missing medication for one of three residents reviewed (Resident R1).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for two of three residents reviewed (Residents R1 and R2).

Inspectors wroteBased on review of facility policies, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nursing staff received training on abuse, neglect, exploitation and misappropriation of resident property as required for two of three nursing staff reviewed (Employees E4 and E8).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to ensure that essential equipment was maintained in safe and operating conditions related to the refrigerators in dining rooms for two of two floors reviewed. (Second and Third Floors). Findings Include: An initial tour of the third floor Dining Room was made on 11:55 a.m. on July 2, 2025. Observation of the dining service area for the third floor revealed the ice machine was leaking and had a towel on floor that was saturated as well as visible water around the area, this was confirmed by the Dietary staff, Employee E4. When asked what happens when there is a leak, Employee E4 stated, well, I do not know, that is a different department. Further review of the service area revealed two refrigerators not currently operable. [...]

Inspectors wroteBased on observations, interviews with staff, and a review of facility policy, it was determined that the facility failed to store food, in accordance with professional standards for food service safety. Findings Include: Review of facility Policy titled, Food Storage: Cold Foods, last revised February 2023 states, Policy Statement- All Time/Temperature Control for Safety (TSC) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures- 5. All foods will be stored wrapped or covered in containers, labeled and dated, and arranged in a manner to prevent cross contamination. A tour of the facility kitchen area was conducted on July 2, 2025, at 10:05 a.m. with the Director of Dining Employee E3. During observation several items were observed in the walk-in refrigerator undated or labeled improperly. [...]

Inspectors wroteBased on review facility policy, review of facility documentation, review of clinical records, interview staff, it was determined that the facility failed to ensure that a resident was free of neglect related to provision of incontinence care for one of twelve residents reviewed. (Resident R12)

Inspectors wroteBased on review facility policy, review of facility documentation, review of clinical records, interview with residents and staff, it was determined that the facility failed to ensure adequate number of nurse aides to meets the needs of residents on one of two nursing floors (2nd Floor) one of twelve residents reviewed. (Resident R12)

Inspectors wroteBased on observations, clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide reasonable accommodations of needs relating to a bariatric bed and a functioning heater for two of 31 residents reviewed.(Residents R251 and R248)

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to diabetes management for one of 24 residents reviewed (Resident R24).

Inspectors wroteBased on observations, staff interviews, and review of clinical records, it was determined that the facility failed to ensure that weekly weights were obtained for two out of twenty-four residents reviewed with a history of weight loss (Resident R39 and Resident R74).

Inspectors wroteBased on observation, review of facility policy and interviews with staff, it was determined that the facility did not maintain respiratory equipment according to professional standards of practice for two of twenty-four residents reviewed. (Resident R17 and Resident R56)

Inspectors wroteBased on observation, review of facility policies and interview with staff, it was determined that the facility failed to ensure that a medication cart was kept locked when not in use and that medications were properly stored for two of two carts. (Medication Cart A and Medication Cart B)

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility did not provide foods in accordance with resident preferences for three of 24 residents reviewed (Residents R43, R42 and R19).

Inspectors wroteBased on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store food, in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that staff were licensed and registered in accordance with State laws for three of 11 personnel files reviewed (Employees E21, E17 and E16).

Inspectors wroteBased upon observation, interviews and review of clinical records and facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of multi-drug resistant organism (MDRO) transmission for one of 31 residents reviewed. (Resident R35)

Inspectors wroteBased on review of personnel records and interviews with staff it was determined that the facility failed to ensure that nurse aides received at least 12 hours of in-service education per year as required for one of six nurse aide personnel files reviewed (Employee E9).

Inspectors wroteBased on observations, staff interviews, and the review of facility documentation, it was determined that the pharmacy failed to timely respond to the facility inquiry of a possible error in the dispensing of a medication for 1 out of 4 residents reviewed (Resident R1).

Inspectors wroteBased on interview with residents and staff and review of facility documentation, it was determined that facility did not ensure residents were treated with dignity and care in a manner and in an environment that promotes the enhancement of their quality of life related to fresh air breaks for thirteen of 19 residents reviewed (R6, R37, R45, R70, R36, R25, R54, R81, R26, R17, R64, R87, R10)

Inspectors wroteBased on observation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for five of 19 residents reviewed (Residents R80, R78, R90, R73, R198 ).

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to maintain the confidentiality of a resident's medical information on one of two nursing units (third floor).

Inspectors wroteBased on review of facility's policies, review of clinical record and interviews with staff, it was determined that the facility failed to ensure that one resident was free from misappropriation of medication for one of 19 residents reviewed (Resident R74).

Inspectors wroteBased on observation, a review of select facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to ensure ongoing evaluation of a resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom for one resident out of 19 sampled residents. (Resident R6)

Inspectors wrote'Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for three of 19 residents reviewed (Residents R6, R83, R86).

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician order was followed related to unplanned weight loss for one of 19 residents with weight loss reviewed (Resident R6).

Inspectors wroteBased on observation, and interviews with staff, it was determined that the facility failed to maintain an environment free from hazards related to an unlocked medication cart and medication unsecured on the cart for one of two nursing units.

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide oxygen as ordered for two of 19 residents (Resident R43, R86).

Inspectors wroteBased on observation, review of facility policy and interview with staff, it was determined that the facility did not ensure that food was served in accordance with professional standards for food service safety for one of 19 residents reviewed (Resident R 47).

Inspectors wroteBased on review of facility documents and interview with staff, it was determined that the facility failed to report a reportable incident via Event Reporting System to the local Department of Health DOH) for one of the 19 residents reviewed within the required and appropriate time frames. (Resident R83)