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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
31D
5E
1F
Potential for minimal harm
0A
0B
0C
April 30, 2026Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, Insulin Glargine's manufacturer's guidelines, and interview with staff, it was determined the facility failed to monitor the blood sugar of resident on Insulin Glargine which resulted in harm to one resident that was transferred to the hospital with Hypoglycemia for one of ten residents on insulin reviewed (Resident R1). This was identified as Past Non-Compliance. Findings Include: Review of the Insulin Glargine's (Lantus) manufacture's guideline revealed under section titled Dosage and Administration: individualized dosage based and metabolic needs, blood glucose monitoring, glycemic control type of diabetes and prior insulin use. [...]
March 10, 2026Complaint inspection · 2 citations
- G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure timely notification to the physician of fall incident sustained by Resident R1. This failure resulted in actual harm to Resident R1 who experienced a delay of treatment after a fall in the shower room with injuries, requiring transfer to the hospital and diagnoses of subdural hematoma, left zygomatic fracture, and acute right 3rd - 4th rib fractures for one of four residents reviewed. This deficiency is being cited as past non- compliance. (Resident R1)
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure that Resident R1 was free of neglect. This failure resulted in actual harm to Resident R1 who sustained a fall in the shower room with resulting physical injuries; delay in timely assessment and medical treatment for one of four residents reviewed. This deficiency was cited as past non compliance,(Resident R1)
January 5, 2026Standard inspection · 10 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of clinical records, facility schedules, staff interviews, and observations, it was determined that the facility failed to ensure residents were provided bathing and showering services in accordance with their assessed needs and physician orders for six of eight residents reviewed. (Residents R33, R43, R174, R164, R185, R180)
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on review of personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required licensure and certifications for three of three employees reviewed. (Employee E13, Employee E14, Employee E15)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, review of facility policy, as well as interview with staff and residents, it was determined that facility did not ensure to honor residents' preferences related to fresh air breaks and activities for two of 33 residents reviewed (Resident R58 and Resident R16). Findings inclide: Review of facility policy 'Activity Programs,' reviewed on April 2025, indicates that activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Further review of policy indicates that activities offered are based on the comprehensive resident-centered assessment and the interest and preferences of each resident. Interview with Resident R58 on Monday, December 29, 2025, at 11:45 am, revealed that the only residents who are accommodated with fresh air breaks are the ones who smoke. [...]
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to accurately document resident council concerns as grievances, failed to record follow-up actions and resolutions in resident council minutes, and did not ensure that residents were informed of outcomes, affecting the resident council's ability to function as a formal grievance forum for 7 of 19 residents in resident council attendance. (Resident 33, R44, R70, R85, R152 and R167)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, staff interviews, and incident/accident documentation, the facility failed to demonstrate that it conducted a thorough, timely, and documented investigation into an allegation of misappropriation of resident property, for one of 33 residents reviewed. (Resident R70)
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to ensure a comprehensive assessment was completed upon admission for one of eight residents reviewed. (Resident R 175)
- 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 policy and interview with staff and residents, it was determined that facility failed to develop and implement a comprehensive resident centered care plan for three of 33 residents reviewed. (Residents R69, and R175)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, review of a facility document, interviews with residents and staff and review of clinical records, revealed that the facility failed to meet the standard of care for diabetes management and hypoglycemia monitoring in a timely manner for one of 11 residents reviewed. (Resident R164)
- D
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 review of facility provided documentation, review of clinical records and interview with staff, it was determined facility did not ensure to complete medication regimen reviews according to professional standards of practice for two of five residents reviewed (Residents R3, and R8)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of facility policy and procedures and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection control program related to water cup distribution for three of 33 residents observed. (Resident R8, Resident R121 and Resident R18)
February 19, 2025Complaint inspection · 1 citation
- 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 clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were updated in a timely manner for one of 10 records reviewed related to resident's behaviors (Resident R1).
December 5, 2024Standard inspection · 9 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, staff and resident interviews, and review of clinical records, it was determined the facility failed to provide the necessary services to maintain adequate grooming and hygiene for one of 33 sampled residents (Resident R315).
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations of the food and nutrition services department, interviews with staff, reviews of policies and procedures and the pest control operator's reports, it was determined that the main kitchen was not maintained and operated to ensure an effective pest control program.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and interviews with residents, it was determined that the facility failed to maintain or enhance the dignity and respect for two of 33 residents reviewed (Resident R38 and R124).
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that a comprehensive assessment was completed accurately related to language and communication for one of 33 records reviewed (R417).
- 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 observation, clinical record review and interview with staff and residents and review of facility policy, it was determined that the facility did not develop a person-centered baseline care plan within 48 hours of a resident's admission related to language and communication for two residents, for a surgically wired jaw for one resident, and mental healthcare needs for one resident of 33 residents reviewed (Resident R158, R315, R417, R420).
- 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, review of facility policy, review of clinical records, and interview with resident and staff, it was determined that the facility failed to develop and implement comprehensive, person-centered care plans to address resident care needs related to a diagnosis of anemia and psychotropic medications for one of 33 resident records reviewed (Resident R314).
- 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 observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for tube feeding management, for one of 33 residents reviewed (Resident R63).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations of care and services, review of clinical record and review of facility policy and interviews with staff and residents, it was determined that the nursing staff failed to obtain and schedule examinations with a specialist as indicated by the physician and to ensure that a medication was administered during the time period prescribed by the physician for two of 47 residents reviewed. (Resident R16 and Resident R315)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of four residents observed during medication administration (Residents R4, and R77).
September 5, 2024Complaint inspection · 3 citations
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on review of facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to identify a bed against the wall and an abdominal binder as a possible restraint and failed to assess the functional status of the resident to determine the use of the restraint for one of eight residents reviewed. (Resident R5) Findings Include: Review of facility policy titled Restraints (Physical) with a revision date of May 5, 2023 states, Policy: The resident has a right to be treated with respect and dignity, including: The right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, clinical record review, interviews with staff, and review of facility policy and procedures, it was determined that the facility failed to ensure that one out of eight residents reviewed were monitored for acceptable parameters of weight. (Resident R5) Findings Include: Review of facility policy titled, Weight and Height Assessment and Interventions with a revision date on March 18, 2024 states, Policy: Purposes of this procedure are to determine the resident's weight and height, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a height in order to determine the ideal weight of the resident. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two residents reviewed. (Residents R2 and R5) Findings Include: Review of the facility policy titled, Dialysis Management (Hemodialysis) with a revision date of March 28, 2024 revealed, It is policy of the facility to ensure that residents who require outpatient hemodialysis treatment have appropriate arrangements made by the facility with an outpatient treatment center in order to provide such services as directed by the physician. Further review of the policy states, If Dialysis is provided at off-site Dialysis Center: 5. Develop a resident binder/folder to send to dialysis with the resident. [...]
May 7, 2024Complaint inspection · 2 citations
- 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 staff interview, observation, and review of facility documentation, it was determined that the facility failed to ensure a safe comfortable homelike environment relating to daily cleaning and pest control for two of 15 residents reviewed. (Resident R12 and R15)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, review of facility policies, and interview with resident and staff, it was determined that the facility failed to ensure one of 14 residents reviewed received assistance with toileting and personal hygiene in a timely manner. (Resident R2)
February 28, 2024Standard inspection · 9 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly. Findings Include: An initial tour of the Food Service Department was conducted on February 25, 2024, at 9:15 a.m. with the Assistant Food Service Director, Employee E4, which revealed the following: Observations of the trash area revealed a large trash compactor. Continued observations revealed a significant build-up of trash, food, and debris surrounding and along the perimeter of the trash compactor. Interview with the Assistant Food Service Director, Employee E4, on February 24, 2024, at 9:20 a.m. confirmed the observations. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, resident and staff interview, it was determined that the facility failed accommodate the residents' needs by failing to provide proper bedding for sleeping for one of 34 residents reviewed (Resident R83).
- 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, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of 35 residents reviewed (Resident R128).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to ensure a dependent resident received assistance with activities of daily living for one of 34 residents reviewed (Resident R40). Findings Include: Review of facility policy ADL (Activities of Daily Living) Care - Supporting Resident revised 01/31/2023 revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident R40's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was cognitively intact and had diagnoses of muscle weakness and abnormalities of gait and mobility. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to clarify physician orders related to insulin, for one of two residents reviewed related to insulin (Resident R14).
- 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 upon interview with resident and staff, review of clinical records and facility policy and procedures, it was revealed the facility failed to ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence for one of 34 resident records reviewed (Resident R122).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to provide residents with respiratory therapy per physician orders for two of two residents reviewed (Residents R40 and R2). Findings Include: Review of facility policy BIPAP (bilevel positive airway pressure - a type of ventilator that helps with breathing by delivering different levels of air pressure to the lungs) and CPAP (continuous positive airway pressure) Policy and Procedure revised May 2021, revealed BIPAP and CPAP is administered by licensed nurses with a physician's order. BIPAP and CPAP may be prescribed for some residents to augment resident breathing when they have difficulty maintaining adequate ventilation. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interviews with resident and staff and review of clinical records and facility policy, it was determined that the facility failed to ensure pain management was provided to a resident consistent with professional standards of practice, the comprehensive care plan and the resident's preferences for one of 34 resident records reviewed (Resident R230).
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on review of facility policy, review of clinical record, observations, and staff and resident interviews it was determined that the facility failed provide food items consistent with the prescribed diet order for one of five residents observed during dining (Resident R40). Findings Include: Review of facility diet guide sheet revealed Sunday lunch offerings on February 25, 2024, was breaded chicken, beef chopped steak, baked fish, mashed potatoes, steamed rice, yellow squash, carrots, and tropical fruit. Per the diet guide sheet, a resident on a Renal (a specialized diet for people with kidney problems)/CCD (carbohydrate controlled) diet should receive steamed rice instead of mashed potatoes. Review of Resident R40's physician orders revealed the resident was ordered a Carbohydrate Controlled/Renal diet dated January 23, 2024. [...]
January 25, 2024Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observation, interview with staff and residents and review of facility policy, it was determined that the facility failed to shower residents on a regular basis for seven out of seven residents reviewed (Residents R1, R2, R3, R4, R5, R6 and R7)
November 20, 2023Complaint inspection · 2 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to prepare and serve items as planned on the menu and failed to provide residents with their requested foods of preference for four of seven residents interviewed (Residents R7, R8, R9 and R11).
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of clinical records and a staff interviews, it was determined that the facility failed to ensure that the resident's representative was notified timely about a change in condition requiring antibiotic therapy for one of four records reviewed (Residents R1).
Fire safety inspections
14 fire safety citations on file: 5 on January 5, 2026, 4 on December 5, 2024, 5 on February 28, 2024.
Every fire safety citation14 citations
- E
Have properly located and lighted "Exit" signs.
K 293 · January 5, 2026 · 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 · January 5, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 5, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 5, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 5, 2026 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · December 5, 2024 · 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 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 28, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 28, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 28, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 28, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 28, 2024 · Corrected (the home has a date of correction)