Zerbe Sisters Nursing Center,
Inspection history, citations, penalties and survey trends for this long-term care facility in Narvon, Pennsylvania.
- Location
- 2499 Zerbe Road, Narvon, Pennsylvania 17555
- CMS Provider Number
- 395326
- Inspections on file
- 16
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Zerbe Sisters Nursing Center, during CMS and state inspections, most recent first.
A resident with a history of falls and mobility issues required two-person assistance for transfers. However, a single nurse aide attempted the transfer, resulting in the resident being lowered to the floor when their knees buckled. The facility's investigation confirmed the deviation from the care plan, as the aide did not wait for additional assistance and did not use a gait belt.
The facility failed to document medication disposition for two discharged residents, violating its policy on pharmaceutical services. One resident expired while hospitalized, and no medication disposition form was found. Another resident was discharged home, but the medication list lacked the quantity of medications dispensed. The DON confirmed these documentation issues.
The facility failed to maintain the smoke resistance of smoke barrier walls, as an unprotected penetration was found above the East Hall smoke barrier cross-corridor doors. This issue was confirmed by the Maintenance Manager during an interview.
The facility failed to document the inspection of diesel fuel quality for the emergency generator within the past year, as required by NFPA standards. The last recorded inspection was over a year ago, and the Maintenance Manager confirmed the absence of recent documentation.
The facility was found to have exceeded the maximum allowable story height for a Type III (200), unprotected ordinary structure. This was observed during a survey, and the Maintenance Manager confirmed the building's construction type exceeded the permitted number of stories for health care facilities.
The facility failed to comply with NFPA 101 requirements by not providing at least two remote exits for two of its smoke compartments. Observations revealed that the 2nd floor Annex and the basement lacked the necessary exits. This was confirmed by the Maintenance Manager.
The facility did not have documentation verifying that the Kitchen Fire Suppression System was inspected semi-annually within the past year. An interview with the Maintenance Manager confirmed the absence of inspection records since March 2024.
Inadequate Supervision During Toileting Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision during a toileting transfer for Resident 55, resulting in a fall. Resident 55, who has a history of repeated falls, generalized weakness, and impaired mobility, required extensive two-person assistance for transferring and toileting as per their care plan. On the day of the incident, the resident was being transferred from the toilet to a wheelchair by a single nurse aide, despite the care plan specifying the need for two-person assistance. During the transfer, the resident's knees buckled, and the aide lowered the resident to the floor. The facility's investigation revealed that the nurse aide, Employee E3, did not wait for a second person to assist with the transfer, as instructed by Employee E4, who was responsible for orientation. Additionally, a gait belt was not used during the transfer, which was a deviation from the standard procedure. The Director of Nursing confirmed that the resident required two-person assistance, and the failure to provide this level of care resulted in the resident being lowered to the floor during the transfer.
Failure to Document Medication Disposition for Discharged Residents
Penalty
Summary
The facility failed to document medication disposition for two discharged residents, leading to a deficiency in pharmaceutical services. According to the facility's policy, the disposal of controlled substances must occur immediately, or within three days, after discontinuation of use by a resident. This disposal must be documented on a medication disposition record with the signatures of at least two witnesses. However, for Resident 76, who expired while hospitalized, there was no medication disposition form found in the clinical records. Resident 76 had been transferred to the hospital due to a change in mental status and shortness of breath and was admitted with congestive heart failure exacerbation. For Resident 7, who was discharged to home, the clinical records included a medication list but failed to document the quantity of each medication dispensed. The discharge summary indicated that medication reconciliation was completed, but the medication disposition sheet did not include the necessary details. An interview with the Director of Nursing confirmed the absence of a medication disposition sheet for Resident 76 and the incomplete documentation for Resident 7.
Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring safety in the event of a fire. During an observation, it was found that there was an unprotected penetration in the smoke barrier wall located above the suspended ceiling, specifically above the East Hall smoke barrier cross-corridor doors. This penetration was around gray wires, compromising the integrity of the smoke barrier. The Maintenance Manager confirmed the presence of this unprotected penetration during an interview.
Plan Of Correction
The facility will maintain the rating of the smoke barrier walls. The identified penetration of the smoke barrier wall has been sealed using an approved through penetration fire stop system in order to maintain the rating of the smoke barrier. Other areas within the component shall be rechecked for penetrations and, if found, sealed with approved through penetration fire stop system in order to maintain the rating of the smoke barriers. Ongoing monitoring of penetrations have been added to the electronic task work order system, and shall be overseen by the director of maintenance/designee. Director of Maintenance shall report on any ongoing findings of penetrations and sealing performed to the QAPI committee for review/recommendation for a period of three months. Maintenance staff shall be educated by Administrator on the NFPA 101 Standard for maintaining smoke barrier walls.
Failure to Document Diesel Fuel Quality Inspection for Emergency Generator
Penalty
Summary
The facility failed to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been inspected within the previous twelve months. This deficiency was identified during a document review conducted on February 11, 2025, at 10:30 AM. The review revealed that the last documented inspection of the diesel fuel quality was dated February 8, 2023, indicating a lapse in the required annual inspection schedule. An interview with the Maintenance Manager on the same day confirmed the absence of documentation verifying the inspection of the diesel fuel quality within the past year. This lack of documentation suggests that the facility did not adhere to the necessary maintenance and testing protocols for the emergency generator's fuel supply, as required by the relevant NFPA standards.
Plan Of Correction
Contractor has been contacted to schedule testing of the emergency generator fuel. Testing frequency has been added to the electronic work order system to ensure notification of future scheduling with the contractor. Administrator and Maintenance Director shall review upcoming required tests in the electronic task work order system during monthly meeting, to ensure proper scheduling is completed in future. The Maintenance Director shall be responsible for assuring the completed testing documentation is filed in the Life Safety book for future reference. Scheduling of and completion for required contractor tests and inspections shall be reported by Director of Maintenance to QAPI committee for review/recommendation for three months. Maintenance department has been educated by Administrator on the requirement for testing the diesel fuel for the emergency generator.
Building Construction Type Exceeds Allowable Height
Penalty
Summary
The facility failed to maintain building construction requirements, specifically exceeding the maximum allowable story height for a Type III (200), unprotected ordinary structure. This deficiency was identified during an observation on February 11, 2025, at 12:30 PM, which revealed that the building's construction type exceeded the number of stories permitted for health care facilities. The Maintenance Manager confirmed this finding during an interview conducted at the same time, indicating a lapse in adhering to the established building construction standards for the facility.
Non-Compliance with NFPA 101 Exit Requirements
Penalty
Summary
The facility was found to be non-compliant with the NFPA 101 requirement for providing at least two exits, remote from each other, for each story and smoke compartment. During an observation conducted on February 11, 2025, between 11:30 AM and 1:30 PM, it was noted that two of the seven smoke compartments within the component lacked the required exits. Specifically, the 2nd floor Annex and the basement did not have two exits that were remote from each other. This deficiency was confirmed through an interview with the Maintenance Manager at 1:30 PM on the same day.
Lack of Documentation for Kitchen Fire Suppression System Inspection
Penalty
Summary
The facility failed to provide documentation verifying that the commercial Kitchen Fire Suppression System had been inspected on a semi-annual basis within the previous twelve months. During a document review on February 11, 2025, it was discovered that there was no documentation available to confirm that the Kitchen Fire Suppression System had been inspected since March 6, 2024. This deficiency was confirmed during an interview with the Maintenance Manager, who acknowledged the lack of documentation for the required inspection of the Kitchen Suppression System.
Plan Of Correction
Inspection of the Kitchen Suppression System has been scheduled with the contractor. Inspection of the Kitchen Suppression System shall be added to the electronic task work order system by the Maintenance Director to alert when to schedule each regulatory required inspection based upon its frequency requirement. The Maintenance Director/designee shall monitor, maintain and update the electronic task work order system weekly for upcoming and completed regulatory required inspections. Administrator and Maintenance Director shall review upcoming required tests and inspections in the task work order system during monthly meeting, to ensure proper scheduling. The Maintenance Director shall be responsible for assuring the completed inspection documentation is properly filed in the Life Safety book. Administrator shall educate the maintenance department regarding semi-annual inspection requirement of the Kitchen Suppression System.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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