Inspection visit

Health inspectionMay 10, 2024

BRINTON MANOR NURSING AND REHABILITATION CENTERCMS #3959174 citations on this visit

4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and personnel records, it was determined that the facility failed to complete a criminal background check upon hire for one of five employee personnel records reviewed (Employee E4). Residents Affected - Few Findings include: Review of facility policy, Background Screening Investigations, last revised March 2019, revealed: The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. Review of nurse aide Employee E4's personnel record revealed a hire date of February 23, 2024, with a criminal background check obtained May 8, 2024. Interview with the Nursing Home Administrator on May 9, 2024, at 1:30 p.m. confirmed nurse aide Employee E4 did not have a criminal background check upon hire. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 395917 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brinton Manor Nursing and Rehabilitation Center 549 Baltimore Pike Glen Mills, PA 19342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, it was determined that the facility failed to provide treatment and services to maintain/restore bladder continence for one of two residents reviewed for bowel and bladder (Resident 31). Findings include: Review of Resident 31's Quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated January 9, 2024, revealed under Section H - Bladder and Bowel, that the resident was coded as being always continent of bladder. Review of Resident 31's Quarterly MDS dated [DATE], revealed under Section H - Bladder and Bowel, that the resident was coded as being occasionally incontinent of bladder. Review of Resident 31's Bowel and Bladder Program Screener dated March 25, 2024, revealed the resident voided appropriately without incontinence at least daily, was independently but slowly able to get to the bathroom/toilet/commode/adjust clothing/and wipe self, was forgetful but able to follow commands, and was usually mentally aware of the need to toilet. The evaluation concluded that Resident 31 was a candidate for scheduled toileting/timed voiding. Review of Resident 31's clinical record failed to reveal a plan of care in place addressing the resident's incontinence and failed to reveal evidence that the resident was ever offered scheduled toileting/timed voiding. The abovementioned findings were presented to the Nursing Home Administrator and Director of Nursing on May 9, 2024, at approximately 2:00 p.m. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395917 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brinton Manor Nursing and Rehabilitation Center 549 Baltimore Pike Glen Mills, PA 19342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to monitor weight changes in a timely manner for one of seven residents reviewed for nutrition (Resident 62). Residents Affected - Few Findings include: Review of facility policy, Weight Assessment and Intervention, last revised March 2022, revealed: Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. Review of Resident 62's weights revealed that on November 25, 2023, the resident was recorded as weighing 180 pounds (lbs.) On December 5, 2023, the resident was recorded as weighing 199.3 lbs., a 19.3 lb. gain or 10.72% weight change in 10 days. Review of Resident 62's progress notes revealed a Weight Change note from the dietitian on December 6, 2023, which stated: Reweight requested for 19 [pound] gain x 2 weeks. No noted fluid retention. Reviewed provider notes 12/5, [abdomen] pain noted. Intake trending >75%. Will follow. Review of Resident 62's weights revealed the next weight obtained was on December 18, 2023, 13 days past the initial weight change recording and 12 days following the dietitian's request for a reweight. Interview with the dietitian, Employee E3, on May 9, 2024, at 12:10 p.m. confirmed the facility failed to obtain a reweight for Resident 62 in a timely manner. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395917 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brinton Manor Nursing and Rehabilitation Center 549 Baltimore Pike Glen Mills, PA 19342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of one resident reviewed (Resident 20). Residents Affected - Few Findings include: Review of Resident 20's Minimum Data Set (MDS, periodic assessment of resident needs) dated April 19, 2024, reviled in Section J (Health Conditions) that Resident 20 receives a scheduled pain medication regimen. Review of Resident's 20 clinical record revealed an active order for Oxycodone (semi-synthetic opioid used medically for treatment of moderate to severe pain) HCL 10 MG (milligrams) with a start date of April 11, 2023, Further review of the order revealed the following, Give 1 tablet by mouth three times a day for severe pain 8-10. Review of Resident 20's electronic medication administration record (eMAR) for the month of April 2024, revealed Resident 20 was administered oxycodone 10 mg a total of 58 times to treat a reported pain of 0 out of 10 (0 being no pain and 10 indicating severe pain). An interview conducted with Registered Nurse (Employee E1) on May 9, 2024, at 12:34 p.m. reported we just write down 0, Resident 20 always has pain, or so she says. An interview conducted with the Nursing Home Administration (NHA) on May 9, 2024, at 1:50 p.m. confirmed Registered Nurse (Employee E1) should have been accurately recording Resident 20's pain severity in the eMAR prior to administering Resident 20's scheduled pain medication. 28 Pa Code 211.10 (c) Resident Care Policy 28 Pa Code 211.12 (d)(1) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395917 If continuation sheet Page 4 of 4

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Citations

4 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0606GeneralS&S Dpotential for harm
F606 - The facility must—
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.

FAQ · About this visit

Common questions about this visit

What happened during the May 10, 2024 survey of BRINTON MANOR NURSING AND REHABILITATION CENTER?

This was a inspection survey of BRINTON MANOR NURSING AND REHABILITATION CENTER on May 10, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BRINTON MANOR NURSING AND REHABILITATION CENTER on May 10, 2024?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Not hire anyone with a finding of abuse, neglect, exploitation, or theft."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 10, 2024