Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 53 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
45D
3E
1F
Potential for minimal harm
0A
0B
3C
July 10, 2026Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to conduct a complete and thorough investigation regarding an allegation of fraud for one of one investigation reviewed.
May 20, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of clinical records, facility documentation, and staff interview, it was determined the facility failed to report a resident's self-injurious behavior resulting in injury requiring hospital transfer and sutures to the Department of Health for one of three residents reviewed (Resident R1).
April 14, 2026Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, review of facility polices and documents, clinical record review and interviews with staff, it was determined the facility failed to properly supervise a cognitively impaired resident who was able to exit the facility and board a train, for one of five residents reviewed for elopement risk (Resident R1). This failure placed the resident in an Immediate Jeopardy situation.
March 4, 2026Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview with resident and staff, review of facility policy and documentation as well as review of clinical record, it was determined that facility failed to provide respiratory care to one resident according to professional standards of practice for Resident R3.
December 1, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a safe, clean, and sanitary environment in resident-use and service areas for one of two nursing units. (Second floor)
July 3, 2025Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review, and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error related to the administration of antihypertensive medication outside of parameters ordered by the physician for one of 5 residents reviewed (Resident R1).
May 29, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of clinical records, facility policy, and interviews with staff, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of four residents reviewed (Resident R1).
March 13, 2025Standard inspection, Complaint inspection · 11 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on review of facility policy, observation, clinical record review and interview with staff/residents/family, it was determined that the facility did not ensure that privacy and confidentiality of person medical information was maintained for six of six residents reviewed (Residents R4, R122, R128, R131, R171, and R199).
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on review of facility policy, review of clinical records and staff interview, it was determined that the facility did not ensure that residents were free of misappropriation of resident property related to diversion of a narcotic medication for one of three residents reviewed who were prescribed narcotic medications. (Resident R416)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards when the facility failed to ensure vital signs were obtained and hypoglycemic protocols were implemented in accordance with physcian orders for three of 35 resident records reviewed (Residents R28, R65, and R123).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of clinical records, facility policy, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care related to oxygen therapy for two of three residents reviewed receiving oxygen therapy. (Resident R85, R99)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, review of facility documents and interview with staff, it was determined that the facility failed to ensure that drug records were accurate and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 3 residents reviewed (Resident R141 and Resident R416)
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to obtain physician orders to allow a resident to store a medication at bedside and further failed to ensure the medication was stored in a safe, secured location for one of 35 resident records reviewed (Resident R26).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to proper disposal and storage of used and potentially contaminated suctioning devices and the use of a urinary catheter tubing and drainage bag in accordance with professional standards for one of two residents reviewed. (Residents R99 and R128).
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to provide a sanitary and comfortable environment for 2 of 10 residents. (R130 and R160)
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on review of facility policy, observations, and staff and resident interviews it was determined that the facility failed to maintain an effective pest control program for one of five nursing units (2nd floor).
- C
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a review of clinical records, review of facility documentation, and staff interview, it was determined that facility failed to timely provide notices of Medicare non coverage (payment) for three out of three residents and failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two out of three residents reviewed (Resident R76, R161, and R117). Findings Include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. [...]
- C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for three of three residents reviewed for hospitalizations (Resident R171, R136, and R123). Findings Include: Review of Resident R123's clinical record revealed the resident was sent to the hospital on December 2, 2024 and December 26, 2024. Review of facility documentation revealed the facility failed to notify the Office of the State Long-Term Care Ombudsman. This was confirmed with the Nursing Home administrator on March 13, 2025 at 12:33 p.m. [...]
November 5, 2024Complaint inspection · 4 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on the review of facility assessment, facility staffing schedule, clinical records, and interviews with staff, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing and related services, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for three of four units reviewed. (Second floor, A unit and D unit). Findings Include: Review of facility assessment dated [DATE], revealed that Staffing plan: 3.2. Accela Rehab and Care at Somerton provides adequate daily staffing based on census, acuity and diagnosis of our resident population to ensure individualized patient-centered care needs are met. Individual staff assignment 3.3. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, staff interviews, review of clinical records and facility documentation, it was determined that the facility failed to administer diabetic medications in accordance with professional standards of for five of five clinical records reviewed of residents who were order antidiabetic medication (Resident R1, R6, R9, R13 and R17). Findings Include: Review of facility policy Administering Medications, dated April 2019, revealed that Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of physician orders and medication administration record for Resident R1 for November 2024 revealed orders for the following medications: [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on the review of clinical records and interviews with staff, it was determined that the facility did not maintain accurate clinical records for two of five residents reviewed. (Resident R1 and Resident R5) Findings Include: Review of an undated facility document Medication Administration Policy revealed that Medications should be administered at the times that are order and signed out immediately when given. Observation of the facility second floor revealed that Licensed Nurse, Employee E3 was administering medications on November 5, 2024, at 10:57 a.m. She stated she was administering morning medications which mostly scheduled for 9:00 a.m. Licensed nurse, Employee E3, stated she had four more residents to finish. Licensed nurse, Employee E3 stated she had to finish 9 a.m. med pass for Resident R1, R2, R3 and R4. [...]
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to accurately post information regarding daily nurse staffing data as required.
September 30, 2024Complaint inspection · 1 citation
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure that a safe, functional, and comfortable environment was maintained for two of ten residents observed.
June 13, 2024Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, review of resident records, and interviews with staff it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of nine residents reviewed. (Resident R1) Findings Include: Review of resident Minimum Data Set (MDS) revealed an admission date of August 18, 2022. The resident was admitted with a diagnosis of pulmonary embolism, seizures, tachycardia, chronic viral hepatitis, respiratory failure, hypocalcemia, depression, anxiety, hypertension, alcohol dependence with withdrawal, insomnia, bilateral primary osteoarthritis, adjustment disorder, and basal cell carcinoma of the skin. [...]
May 3, 2024Standard inspection, Complaint inspection · 13 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on a review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of 36 residents reviewed (Resident R54, R26, R61) Findings Include: Review of the Pharmacy Services - Role of the Consultant Pharmacist Policy dated April 2019, revealed, the consultant pharmacist will provide specific activities related to medication regimen review including a documented review of the medication regimen of each resident at least monthly, appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities and pertinent resident-specific documentation in the medical record. [...]
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and resident interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition for 2 of 5 nursing units (1st and 2nd floor).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility provided documentation and interview with staff, it was determined that the facility failed to conduct a complete and thorough investigation related to missing narcotics for three residents reviewed (Residents R163, R500, R501)
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on review of clinical records, review of facility provided documentation and interview with staff, it was determined that the facility did not develop and implement a comprehensive person-centered care plan related to urinary tract infection for one of 35 residents reviewed. (Resident R47)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, and interviews with staff, it was determined that the facility failed to maintain an environment free from hazards related to cleaning supplies left in the one resident's room in one of five units (A unit)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, review of clinical record, review of facility policy and staff interview, it was determined that the facility failed to ensure proper care of a urinary catheter bag and that a physician order was obtained to perform self catherization flushes for one of one residents review with a urinary catheter.(Resident R9)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable an accurate reconciliation and accountability for one of four medication carts observed (unit Second Floor A).
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards for one of two medication rooms observed. (First floor Unit A)
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of facility documents, staff interview and review of facility policy, it was determined that the facility failed to ensure that proper infection control practices were followed according to professional standards related to enhance barrier precaution during wound care for one of 35 residents reviewed. (Resident R103)
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations of the physical environment, review of pest control logs, review of pest control reports, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program. Findings Include: Review of the facilities pest control policy Titled, Pest Control dated May 2008 states, Policy Statement, Our facility shall maintain an effective pest control program. The Policy Interpretation and Implementation states, 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by __(left blank)___. 3. Windows are screened at all times. 4. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. 5. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, review of clinical record, review of facility policy and staff and resident interviews, it was determined that the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure to ensure that MAR (medication administration record) documentation during medication administration was conducted according to professional standards for six of seven residents observed. (Residents R33, R38, R104, R139, R165 and R180)
November 30, 2023Complaint inspection · 1 citation
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on clinical record reviews, interviews with staff and reviews of policies, procedures and the respiratory service agreement, it was determined that the facility failed to ensure that routine assessments and monitoring by the respiratory care service and licensed respiratory therapist were completed and availavable for review, for two of three residents with tracheostomy care needs. (Residents R1 and R2)
October 2, 2023Complaint inspection · 2 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop comprehensive person centered care plans related to activities of daily living and activities programs for four of six residents reviewed (Residents R1, R2, R3 and R4).
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide assistance with activities of daily living, including shaving and nail care, for 3 of 6 residents reviewed (Residents R1, R2 and R4).
June 30, 2023Standard inspection · 13 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, review of facility and staff interviews, it was determined the facility failed to maintain a safe, clean, and comfortable homelike environment for two of 4 nursing units (A and D nursing units). Findings Include: Review of facility's 'Homelike Environment' policy, revised on February 2021, states the following: The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment, e. clean bed and bath linens that are in good condition, f. pleasant and neutral scents, g. plants and flowers where appropriate, h. comfortable and safe temperatures (71F - 81F). [...]
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observations, review of clinical records, and staff, resident, and family interviews, it was determined that the facility failed to ensure a baseline care plan was developed related to communication needs and transmission based precautions for one of five new admissions reviewed (Resident R309). Findings Include: Review of Resident R309's clinical record revealed the resident was admitted to the facility June 22, 2023. Review of Resident R309's nursing admission assessment dated [DATE], revealed the resident had aphasia (communication deficit disorder) and was difficult to understand. Review of Resident R309's speech therapy evaluation and plan of treatment for certification period June 27, 2023, through July 26, 2023, revealed the speech therapist was unable to determine cognitive status secondary to severe language impairment. [...]
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was developed and implemented related to oxygen therapy, Activities of Daily Living, and tracheostomy for three of five residents reviewed (Resident R30, R310 and R362).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of clinical record, observation and review of facilty policy, it was determined that the facilty failed to ensure that personal hygiene was timely provided to one of seven residents reviewed. (Resident R7)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observations, clinical record review and staff interview, it was determined that the facility failed to ensure the application of a hand splint for one of one resident reviewed who was ordered for a hand splint (Resident R89).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide enteral feeding in accordance with resident needs and physician orders for one of two residents reviewed with tube-feedings (Resident R309). Findings Include: Review of facility policy Enteral Tube Feeding via Continuous Pump revealed staff should verify that there is a physician's order for this procedure and review the resident's care plan and provide for any special needs of the resident. Review of Resident R309's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of gastrostomy status (surgical procedure for inserting a tube into the stomach through the abdomen used for delivering nutrition formula). [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 33 residents reviewed (Residents R30).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interviews with staff and review of facility policies and procedures, it was determined that the facility did not ensure that narcotic medication was disposed of in accordance with federal, state, and local regulations and did not ensure physician ordered medications were obtained from the pharmacy in a timely manner (Resident R309).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure one resident was free from significant medication error for one of five new admissions reviewed (Resident R309). Findings Include: Review of facility policy Adverse Consequences and Medication Errors revealed a medication error is defined as the preparation or administration of drugs which is not in accordance with physician's orders. Example of medication error includes omission - a drug is ordered but not administered. The attending physician should be notified promptly of any significant error. Further review of facility policy revealed the following information should be documented on in an incident report and in the resident's clinical record: 1. Factual description of the error, 2. Name of physician and time notified, 3. [...]
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory studies were obtained as ordered by the physician for one of 33 residents reviewed (Resident R37).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of seven residents with hospice care reviewed (Resident R259).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to implement a system for the identification of and control measures for Legionella (bacteria that causes disease found in contaminated water) as required.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain an effective pest control program for one of four nursing units (A Wing). Findings Include: Review of Resident R309's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of tracheostomy status (plastic tube placed through a small surgical opening through the front of the neck into the windpipe allowing air to flow in and out). Observations on June 28, 2023, at 11:50 a.m. confirmed Resident R309 had a tracheostomy. Observations on June 28, 2023, at 11:50 a.m. revealed small gnats in the residents bathroom and a fruit fly hovering around the resident's head. Interview on June 28, 2023, at 11:56 a.m. with nurse aide, Employee E8, confirmed the presence of flies in the room and reported there's flies in every room. [...]
Fire safety inspections
6 fire safety citations on file: 2 on March 13, 2025, 1 on May 3, 2024, 3 on June 30, 2023.
Every fire safety citation6 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · May 3, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 30, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 30, 2023 · Corrected (the home has a date of correction)