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 88 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
5G
0H
0I
Potential for more than minimal harm
57D
18E
7F
Potential for minimal harm
0A
0B
0C
July 24, 2026Standard inspection, Complaint inspection · 15 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of a pressure ulcer. This resulted in actual harm of the development of a facility-acquired Stage 3 (full thickness skin loss that extends into the subcutaneous fat) pressure ulcer for one of three residents (Resident R1).
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on a review of observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions creating the potential for cross contamination in the main kitchen of the facility.
- 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 review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for three of seven residents (Resident R4, R11, and R26).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for two of five residents (Residents R67 and R85).
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on review of resident records, resident business office documents and staff interview, it was determined that the facility failed to ensure that a resident right to manage their financial affairs was upheld by obtaining a signed authorization for one of three sampled resident records (Resident R37).
- 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 review of facility policy, observations, resident and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for one of five resident wheelchairs (Resident R5) and failed to have bath linens in good condition for one of three bath linen items (washcloths).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster (a long, thick cushion) is a restraint for one of two residents (Residents R1).
- D
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, and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of six residents (Residents R1 and R4).
- 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 review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide written summary of the baseline care plan to the resident and/or representative for two of six residents reviewed (Resident R78 and R94).
- 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, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents (Residents R64).
- 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, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Resident R64).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Residents R64 and R85).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for a resident who was at risk for re-traumatization for one of two residents (Resident R30).
- 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 store medications and biologicals in a safe, secure, and orderly manner for one of three medication rooms (3 South Medication Room).
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of five residents reviewed (Closed Resident Record CR99).
March 18, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician order to discharge for two of three residents (Resident R1, R2).
February 23, 2026Complaint inspection · 3 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policy, clinical record review, 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 for three of four residents sampled with facility-initiated transfers (Resident R1, R2, and R3), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of four resident hospital transfers (Resident R1, R2, and R3).
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of facility policy, Resident Council meeting minutes, and staff interviews, it was determined the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for three of three months (December 2025, January 2026, and February 2026).
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory results as ordered by the physician and failed to provide evidence that the physician or resident representative were notified of the results for two of three residents reviewed (Resident R3, and R4).
January 8, 2026Complaint inspection · 1 citation
- D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for four of 12 months (October 20, 2025, through January 8, 2026).
December 1, 2025Complaint inspection · 1 citation
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, resident and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for approximately 38 out of 76 residents.
June 26, 2025Standard inspection · 9 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 facility policy, observations and staff interview, it was determined that the facility failed to properly label and date food products, in the Main Kitchen. (Main Kitchen).
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to individualize care plans to address the resident specific nutritional concerns for two of three residents (Resident R9, and R31), and failed to ensure direct care staff were aware of residents with fluid restriction orders to make certain acceptable parameters of nutritional status were maintained for one of two residents on physician ordered fluid restrictions (Resident R34).
- 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 review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and failed to ensure that any irregularities submitted in the MRR by pharmacy were acted upon timely for three of five residents (Residents R29, R33, and R46).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Resident R9).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for two of four residents (Residents R33 and R46).
- 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 clinical record review, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Residents R31).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of two residents (Resident R30 and R38).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of three residents (Resident R34).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of two sampled residents (Resident R58).
May 28, 2025Complaint inspection · 5 citations
- G
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 and staff interviews, it was determined that the facility failed to develop a comprehensive care plan to meet resident care needs for two of four residents (Resident R1 and R2), which resulted in harm, when a resident was rolled out of bed without the correct level of assistance and sustained bilateral leg fractures (Resident R1). Findings Include: [...]
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to provide appropriate care and treatment for one of four residents (Residents R1), which resulted in harm, and Resident R1 required a blood transfusion.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided for one of four residents (Residents R1), which resulted in harm when Resident R1 rolled out of bed and sustained bilateral leg fractures.
- 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 documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of five residents (Resident R1).
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was timely completed after a fall for one of four residents reviewed (Resident R1).
March 27, 2025Complaint inspection · 4 citations
- 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 provided documentation, and staff interviews, it was determined that the facility failed to protect one of four residents (Resident R1) from sexual abuse, prevent psychosocial and/or physical harm, and physical discomfort that resulted in actual harm for Resident R1.
- D
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 facility policy, education literature, clinical record review, and staff interviews, it was determined that the facility failed to recognize and report timely suspicions of sexual abuse for one of three residents (Resident R1) until it was actually witnessed by a staff member.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on clinical record and facility document review and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to ensure safety for one of three residents (Resident R1).
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents to prevent sexual abuse.
January 30, 2025Complaint inspection · 3 citations
- E
Provide or obtain dental services for each resident.
Inspectors wroteBased on clinical record review, facility documents and staff and resident interview, it was determined that the facility failed to provide dental services to meet the needs of residents for three of four residents reviewed (Residents CR1, R2, and R3).
- 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, facility documents, and staff interviews, it was determined that the facility failed to notify the family of a change in condition in a timely manner for one of three residents (Resident CR1).
- 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 review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for one of three residents reviewed (Resident CR1).
December 19, 2024Complaint inspection · 2 citations
- D
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Inspectors wroteBased on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation three two of seven residents (Resident R1, R2, R3).
- D
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 staff interview, it was determined that the facility failed to properly label and date food products on the nursing unit pantries which created the potential for cross contamination in the designated kitchen pantries.
October 23, 2024Complaint inspection · 1 citation
- 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 policy, review of clinical documentation and staff interview it was determined the facility failed to have accurate narcotic count sheets from shift to shift, failed to document the disposition of narcotics accurately, and failed to identify discrepancies between Medication Administration Records and narcotics count sheets for three of five closed record residents (CR Resident R1, CR2, and CR3). Review of facility policy Management of Controlled Drugs, dated 8/24/23, indicated Schedule II to V controlled drugs must be disposed of in accordance with federal and state regulations. Review of facility documentation shift count ( a tool used for nursing to confirm the narcotic count is accurate shift to shift ongoing/off-going) for 3rd floor indicated the following: 10/6/24 status of count: [...]
August 8, 2024Standard inspection, Complaint inspection · 22 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, clinical records, facility investigation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision, assistance, and proper equipment to prevent injuries during a transfer for one of four residents reviewed (Resident R47). This failure resulted in Resident R47 having pain, bruising, and was transferred to the hospital and diagnosed with a fractured rib, which were sustained during an improper transfer. The facility failed to maintain resident Kardexes (a snapshot of resident care needs) and care plans to reflect accurate mobility transfer statuses. This failure created an Immediate Jeopardy situation for nine of 17 residents reviewed (Residents R47, R7, R21, R29, R33, R37, R51, R68, and R75).
- F
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 resident interviews, staff interviews, resident council minutes, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Resident R11, R28, R32, and R69). Findings Include: Review of the facility's PBJ Staffing Data Report Quarter 4 2023 (July 1 - September 30) indicted the facility was triggered for one star staffing rating and excessively low weekend staffing. Review of the facility's PBJ Staffing Data Report Quarter 2 2024 (January 1 - March 31) indicted the facility was triggered for one star staffing rating and excessively low weekend staffing. [...]
- 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, observations and staff interview, it was determined the facility failed to properly serve food in a sanitary manner to prevent foodborne illness in the Main Kitchen.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on a review of facility policies, facility documents, observations, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to make certain that necessary care and services were provided to residents to ensure safe resident mobility transfers.
- F
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 a review of facility documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements.
- E
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on review of clinical record review, 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 for five of five residents sampled with facility-initiated transfers (Residents R6, R44, R51, R62, and R83).
- E
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 policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of three residents (Residents R51, R62, and R83).
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Residents R6, R44, R51, R62, and R83).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy, resident interviews and observations, and staff interview it was determined that the facility failed to provide a beautician services for four of seven residents (Residents R6, R24, R32, and R61).
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for four of four residents (Residents R7, R21, R37, and R79).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review, observations, and staff interview, it was determined the facility failed to provide appropriate care and services to residents receiving medications via feeding tube for two of three residents reviewed (Residents R23 and R29).
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (NA Employees E4, E21, E22, E23, and E24)
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on behavioral health for five of five staff members (Nurse Aide Employee E4, E21, E22, E23, and E24).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of facility policy, observations, resident interview, and employee interviews it was determined that the facility failed to accommodate the needs of a resident with a visual impairment for one of two residents (Resident R32).
- 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 policies, clinical records, facility submitted documents, observations, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect for one of six residents (Resident R29).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of two residents (Resident R47), and failed to properly screen an employee by completing a State background check prior to hire for two of five personnel records (Nursing Assistant (NA) Employee E19 and Registered Nurse (RN) Employee E20).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, clinical record review, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect for one of two residents (Resident R47).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per physicians order for two of four residents (Resident R62 and R83).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide prescribed pressure ulcer treatment and services consistent with professional standards of practice for two of two residents (Residents R7 and R29).
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to monitor colostomy site and services consistent with professional standards of practice and failed to implement the colostomy care plan for one of three residents reviewed (Resident R65).
- D
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 a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of three residents (Resident R65, and R79) and failed to obtain a physicians order to admit to hospice for one of three residents (R65).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to implement infection control measures and implement enhanced barrier precautions for residents who required tube feedings for two of three residents (Residents R23, and R29).
May 16, 2024Complaint inspection · 1 citation
- F
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on a review of facility policies, Food Committee Minutes, cycle menus, Always Available Menu, and staff interviews, it was determined that the facility failed to offer alternative menu selections based on resident preferences for four of four weeks of the Spring/Summer cycle menu (Week One, Week Two, Week Three, and Week Four).
April 24, 2024Complaint inspection · 2 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 policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for two of three nursing units (First and Second floor).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to implement its abuse prohibition policies regarding verifying new employees' standing with the Pennsylvania Nurse Aide Registry for one of four new employees reviewed (Nurse Aide, Employee E5) and failed to ensure that reference checks were obtained prior to hire for one of four Nurse Aide files reviewed (Nurse Aide, Employee E5)
April 3, 2024Complaint inspection · 1 citation
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to ensure residents were provided food that accommodates resident's allergies for one of 7 residents reviewed. (Resident R1)
February 20, 2024Complaint inspection · 2 citations
- D
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteBased on a review of employee files and staff interviews, it was determined that the facility failed to ensure that certified nurse aides received registry verification following the expiration of nurse aide registration for one of four nurse aides (Employees E1).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for one out of five personnel files (Employee E1).
December 21, 2023Complaint inspection · 7 citations
- 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 four of 34 residents reviewed (Residents 2, 4, 6, 8). This deficiency was cited as past non-compliance.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policies, manufacturer's instructions, meal schedules, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 34 residents reviewed (Resident 6). This deficiency was cited as past non-compliance.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for one of one newly hired nurses (Registered Nurse 1) and failed to ensure that references were checked from previous employers and/or current employers for one of one newly hired nurses reviewed (Registered Nurse 1). This deficiency was cited as past non-compliance.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility's policies, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency (Department of Health) for one of 34 residents reviewed (Resident 25). This deficiency was cited as past non-compliance.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or misappropriation as the possible cause of a change in condition for one of 34 residents reviewed (Resident 25). This deficiency was cited as past non-compliance.
- D
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 ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physicians' orders were followed, and failed to ensure that hypoglycemia protocols were followed as ordered by the physician for two of 34 residents reviewed (Residents 10, 25). This deficiency was cited as past non-compliance.
- 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 34 residents reviewed (Resident 25). This deficiency was cited as past non-compliance.
October 10, 2023Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for one of two residents (Resident R1).
September 8, 2023Complaint inspection · 7 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of 12 months (October 2022 - January 2023).
- 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 observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for three of eight resident rooms (Resident R37, R47, and R67). Findings Include: Review of the facility policy Quality of Life - Homelike Environment last reviewed 8/24/23, indicated the residents are provided with a safe, clean, comfortable, and homelike environment. Review of the admission record indicated Resident R37 admitted to the facility on [DATE]. Review of Resident R37's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/6/23, indicated the diagnoses of Chronic obstructive pulmonary disease (COPD a lung disease that blocks airflow and makes it difficult to breathe), diabetes (too much sugar in the blood), and quadriplegia (paralysis of all four limbs). Observation of Resident R37's room on 9/5/23, at 9:32 a.m. [...]
- 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 review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included risk for wandering and interventions needed to provide effective and person-centered care for one of twelve residents (Resident R193).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to obtain physician orders for a nothing my mouth (NPO) oral diet order for one of four residents (Resident R73), and failed to notify the physician of decreased Capillary Blood Glucose (CBG) levels and failed to assess a resident with hypoglycemia (low blood glucose), for one of five residents (Resident R43)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident interviews, and staff interviews, it was determined that the facility failed to make certain each resident received timely identification of wandering risk that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R193).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility assessment, facility Nurse Aide job descriptions, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for four out of five personnel files (Nurse Aide Employee E9, Nurse Aide Employee E10, Nurse Aide Employee 11, and Nurse Aide Employee E12).
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on review of facility records and staff interviews, it was determined that the facility failed to have a designated Infection Preventionist (IP) qualified with specialized training in infection prevention and control for three of twelve months (April 2023 - June 2023).
Fire safety inspections
7 fire safety citations on file: 3 on July 24, 2026, 1 on June 26, 2025, 3 on August 8, 2024.
Every fire safety citation7 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 24, 2026 · deficient, provider has
- 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 · July 24, 2026 · deficient, provider has
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 24, 2026 · deficient, provider has
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 8, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 8, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 8, 2024 · Corrected (the home has a date of correction)