Normandie Ridge
Inspection Findings
F-Tag F0686
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or potential for actual harm
Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide care and services consistent with professional standards to promote healing and prevent worsening of pressure injuries for one of two residents reviewed for pressure injuries (Resident 71).Findings include:Review of facility policy, titled Skin Management and Injury and Prevention, last reviewed July 30, 2025, revealed the policy statement was, B. A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing. Subsection I. stated, All resident alterations in skin integrity will be tracked weekly in the [Electronic Medical Record] and reviewed and documented weekly until resolved.Review of Resident 71's clinical record revealed diagnoses that included acute congestive heart failure (decreased ability of the heart to effectively pump blood throughout the body) and unspecified atrial flutter (irregular heart rate).Review of Resident 71's clinical
record revealed that upon re-admission to the facility from a hospital stay on August 8, 2025, Resident 71's sacral area was identified as having intact, dry skin.Review of Resident 71's interdisciplinary progress notes revealed that on August 16, 2025, at 2:48 PM, Employee 4 (Licensed Practical Nurse [LPN]) documented Resident 71 had an open area to left upper buttocks that was approximately 1.0 centimeter (cm - metric unit of measure) by 0.7 cm. The wound bed was documented as having yellow slough (dead cells and/or tissue). The progress note stated that the supervisor was made aware. Further review of the clinical record revealed no progress note or assessment of the newly identified wound was completed by a Registered Nurse. Resident 71's physician's orders, revealed that an order was started to cleanse the wound with Normal Saline Solution (NSS), apply medical honey and cover with boarder gauze.Review of Resident 71's clinical record revealed that the electronic skin/wound assessment tracking form was not initiated until August 25, 2025. Review of Resident 71's clinical record failed to reveal a documented wound assessment (including but not limited to wound size, characteristics, or changes and or improvement) for Resident 71's sacral wound between August 16 and 25, 2025 (total of 9 days).Between the dates of August 16 and 25, 2025, Resident 71 was transferred to a hospital emergency department on August 21, 2025, at approximately 1:04 PM due to abnormal blood laboratory values, and returned to the facility on August 21, 2025, at approximately 7:50 PM. Review of Resident 71's clinical record revealed no reassessment of Resident 71's skin upon return to the facility.On August 25, 2025, at 11:24 AM, Employee 5 (Registered Nurse) documented a wound assessment. According to the wound assessment, Resident 71's sacral wound measured 5.33 cm in length by 1.42 cm in width.During a staff interview on September 26, 2025, at approximately 2:30 PM, the Nursing Home Administrator confirmed that there was no documented wound assessment completed for Resident 71's sacral wound between August 16 and 25, 2025. As of the interview, the facility had no further information to provide.28 Pa code 211.12(d)(1)(3)(5) Nursing services.
Residents Affected - Few
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
Event ID:
F-Tag F0880
Federal health inspectors cited Normandie Ridge in YORK, PA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-26.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of Normandie Ridge.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-22.
Normandie Ridge in YORK, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in YORK, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Normandie Ridge or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.