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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
14D
3E
0F
Potential for minimal harm
0A
0B
0C
March 6, 2026Standard inspection · 3 citations
- 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 policy, observations, and staff interview, it was determined that the facility failed to discard expired multi-dose insulin pens (medication to treat elevated blood sugar levels) in two of four medication carts (A and B Wings) and also failed to safely secure medications on one of four nursing unit medication carts (B Wing).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined the facility failed to maintain privacy of Protected Health Information (PHI) during medication administration for one of six medication passes observed.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policies, clinical records, and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer and failed to have complete documentation related to a transfer for one of two residents reviewed (Closed Record Resident CR77).
January 9, 2026Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide resident-directed care and treatment consistent with physician orders, and professional standards of practice related to medication administration for 37 of 62 residents on two evening shifts on 12/05/25 and 12/06/25. (Residents R1, R2, R3, R4, R6-R28, and R30-R39)
March 28, 2025Standard inspection, Complaint inspection · 4 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that the resident plan of care was followed for one of 18 residents reviewed (Resident R224).
- 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 review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to ensure that a resident with limited range of motion related to a contracture (a permanent or temporary tightening of soft tissues and muscles that restricts normal movements) received physician ordered treatment and services to prevent further decrease in range of motion for one of 18 residents reviewed (Resident R19).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R224).
- 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 policies and manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened and failed to ensure expired medications were discarded in a timely manner in one medication room and in one of two medication carts reviewed (C/B Medication Room and B-Wing Cart).
July 3, 2024Complaint inspection · 1 citation
- D
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on review of facility policy, Pennsylvania Code Title 49. Professional and Vocational Standards, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to follow nursing standards of practice for safe medication administration for one of two residents reviewed for medication administration (Resident R1).
April 12, 2024Standard inspection · 8 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of rights of medication administration, facility policy, observation, and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice for medication administration during observation of one of three resident units (Unit C).
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, review of clinical records and facility policy, and resident and staff interviews, it was determined that the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that are significant to the resident for one of 20 residents reviewed (Resident R17).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain privacy of confidential information during medication administration for one of three resident units (Unit C).
- D
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 and documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of 20 residents reviewed was free of neglect during care. (Resident R8)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of two residents reviewed for respiratory services (Resident R22).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a review of facility policy and closed clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate and safe disposition of controlled medication records for one of three closed records reviewed (Resident CR68).
- D
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 facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to administration of a PRN (as needed) psychotropic (affecting the mind) medication for two of six residents reviewed for unnecessary medications (Residents R39 and R60).
- D
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 a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators reviewed (first floor pantry).
March 7, 2024Complaint inspection · 1 citation
- 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, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a completely dislocated entire left hip hemiarthroplasty (a complete dislocation of a partial hip replacement that replaces half of the hip joint). This deficiency is cited as past non-compliance.
Fire safety inspections
8 fire safety citations on file: 2 on March 6, 2026, 4 on March 28, 2025, 2 on April 12, 2024.
Every fire safety citation8 citations
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 6, 2026 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · March 6, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 28, 2025 · Waiver
- C
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 28, 2025 · 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 · March 28, 2025 · Corrected (the home has a date of correction)
- B
Have power receptacles that are properly grounded.
K 912 · March 28, 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 · April 12, 2024 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · April 12, 2024 · Corrected (the home has a date of correction)