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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
13E
3F
Potential for minimal harm
0A
0B
0C
April 23, 2026Standard inspection · 15 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policies, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin) for one of 40 residents reviewed (Resident 43), resulting in a deterioration of the wound and delayed healing.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the kitchen.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative in writing regarding the reason for transfer to the hospital for six of 40 residents reviewed (Residents 7, 8, 9, 43, 67, and 81).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for six of 40 residents reviewed (Residents 2, 10, 12, 34, 43, 57).
- E
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, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for two of 40 residents reviewed (Residents 1, 2, and 43).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for two of 40 residents reviewed (Residents 44 and 73).
- E
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to coordinate care with the hospice provider by failing to follow recommendations for changes in medications for one of 40 residents reviewed (Resident 38).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for two of 40 residents reviewed (Residents 32 and 78).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 40 residents reviewed (Residents 8 and 43).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for two of 40 residents reviewed (Resident 9, 34).
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on review clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of 40 residents reviewed (Resident 16).
- 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents who were receiving enteral feedings (delivers liquid nutrients directly into the stomach) received appropriate treatment and services to prevent complications for one of 40 residents reviewed (Resident 43).
- 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 observations, and staff interviews, it was determined that the facility failed to provide a separately locked, permanently affixed compartment in the refrigerator for the storage of controlled drugs (medications with the potential to be abused) in one of two medication rooms reviewed.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that laboratory services were obtained as ordered by the physician for one of 40 residents reviewed (Resident 57).
May 22, 2025Standard inspection · 8 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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for five of 38 residents reviewed (Resident 1, 13, 25, 29, 75).
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect a resident's specific care needs for three of 38 residents reviewed (Residents 35, 47, 50).
- E
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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters (a flexible catheter used to drain urine from the bladder into a drainage collection bag) for three of 38 residents reviewed who had an indwelling urinary catheter (Residents 4, 7, 10).
- 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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a care plan was created to reflect the resident's specific care needs for one of 38 residents reviewed (Resident 7).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to safely transfer one of 38 residents reviewed (Resident 62) who required assistance from staff for transfers.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 38 residents reviewed (Resident 35).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
June 6, 2024Standard inspection · 15 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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that a microwave used to reheat resident food was clean (Bayside Nourishment Center), and failing to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (Bayside Nourishment Center).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide nutritional supplements as ordered by the physician for one of 33 residents reviewed (Resident 1), failed to ensure that the hypoglycemic protocol was followed for two of 33 residents reviewed (Residents 3, 38), failed to ensure physician's orders for medications were followed for one of 33 residents reviewed (Resident 48); and failed to ensure that physician's orders for bowel protocols/medications were followed for two of 33 residents reviewed (Residents 7, 74).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for two of 33 residents reviewed (Residents 7, 58).
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 33 residents reviewed (Resident 58).
- E
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 policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in two of three medication rooms reviewed (Landings and Bayside), and failed to discard expired medical supplies.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 33 residents reviewed (Resident 75) who had an indwelling urinary catheter.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to clarify questionable physician's orders for one of 33 residents reviewed (Resident 5).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 33 residents reviewed (Resident 5).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of policies, clinical records, and investigation documents, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by failing to follow physician's orders and care-planned interventions for diets for one of 33 residents reviewed (Resident 29), failed to ensure that care-planned interventions were in place at the time of a fall for one of 33 residents reviewed (Resident 26), failed to follow physician's orders and care-planned interventions to prevent skin breakdown for one of 33 resident's reviewed (Resident 42), and failed to ensure that safe wheelchair transport techniques were used for one of 33 residents reviewed (Resident 79). Findings Include: [...]
- 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 33 residents reviewed (Resident 5) who had an indwelling urinary catheter.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen tubing and a nasal canula remained off the floor for one of 33 residents reviewed (Resident 42). The facility's policy regarding oxygen therapy, dated January 16, 2024, indicated that oxygen was to be administered safely and in accordance with physician's orders. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated March 5, 2024, revealed that the resident was cognitively impaired and had diagnoses that included chronic respiratory failure with hypoxia (a serious condition that causes low blood oxygen) and a history of generalized anxiety. [...]
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 58).
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on review of clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided the proper food consistency as ordered by the physician for one of 33 residents reviewed (Resident 29). This deficiency was cited as past non-compliance.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during wound care for two of 33 residents reviewed (Residents 45, 59).
Fire safety inspections
15 fire safety citations on file: 5 on April 23, 2026, 6 on May 22, 2025, 4 on June 6, 2024.
Every fire safety citation15 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 23, 2026 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · April 23, 2026 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · April 23, 2026 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · April 23, 2026 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 23, 2026 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 22, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 22, 2025 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 22, 2025 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 22, 2025 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · June 6, 2024 · Corrected (the home has a date of correction)
- B
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · June 6, 2024 · Corrected (the home has a date of correction)
- B
Have power receptacles that are properly grounded.
K 912 · June 6, 2024 · Corrected (the home has a date of correction)