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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
13D
2E
0F
Potential for minimal harm
0A
0B
0C
September 18, 2025Standard inspection · 3 citations
- 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 interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of four residents reviewed for hospitalizations (Residents R1, R12, and R57).
- 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, observations, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 16 residents reviewed (Resident R22).
- 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, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of two medication carts reviewed (Cart A) and one of one medication rooms reviewed.
October 24, 2024Standard inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of clinical records and facility documentation, and resident family and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 13 residents reviewed (Resident R26).
August 22, 2024Complaint inspection · 2 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 policies and clinical records and staff interviews, it was determined that the facility failed to ensure that residents were free of neglect during care, which resulted in actual harm of Stage Three (full-thickness skin and tissue loss) pressure ulcer development of the coccyx (small triangular bone at the base of the spinal column), buttocks, and heel for two of two closed records reviewed for pressure areas (Residents CR1 and Resident CR2).
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policy and clinical record and staff interviews, it was determined that the facility failed to ensure that residents were monitored, adequately assessed, and preventative measures were implemented to prevent ulcers from developing or worsening, resulting in actual harm of Stage Three (full-thickness skin and tissue loss) pressure ulcer development of the coccyx (small triangular bone at the base of the spinal column), buttocks, and heel for two of two closed records reviewed for pressure ulcers (Residents CR1 and Resident CR2).
November 15, 2023Standard inspection · 11 citations
- E
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 interview, it was determined that the facility failed to ensure that a baseline care plan was developed/implemented within the required timeframe and failed to ensure that a written copy was provided to residents and resident's representatives for six of 14 residents reviewed (Residents R5, R35, R47, R50, R54, and R58).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility policies, manufacturer's guidelines, Pennsylvania Department of Health PAHAN 694, and clinical records, and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose [sugar] in the blood) for three of 12 residents observed during the administration of medications (Residents R58, R4, and R47), prevent the potential for cross contamination during a dressing change for two of 14 residents (Residents R6 and R22), and failed to ensure SARS-CoV-2 (COVID-19) infection control protocols were followed to help prevent the development and transmission of communicable diseases and infections on one of four nursing units (East Wing).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain resident dignity regarding indwelling foley catheters (a tube inserted into the bladder to drain urine) for two of 14 residents reviewed (Residents R22 and R160).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, review of clinical records and facility policies, and staff interview, it was determined that the facility failed to maintain confidentiality regarding resident medical information for three of 14 residents reviewed (Residents R10, R15, and R26).
- 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, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 14 residents reviewed (Resident R50).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, review of clinical records, and staff interviews, it was determined that the facility failed to provide dining assistance for one of 14 residents reviewed (Resident R19).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to maintain current information related to Hospice services for one of 14 residents reviewed (Resident R19).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policies 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 14 residents reviewed (Resident R58).
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the opportunity for unauthorized access of medications on two of two medication carts (Carts A and B) and failed to label multi-dose insulin (medication to treat elevated blood sugar levels) pens with the date they were opened in one of two medication carts (Cart B).
- 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 facility policy, observations, and staff interviews, it was determined that the facility failed to store food and food containers in a safe and sanitary manner in one of one nourishment refrigerators.
- 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, clinical records, and Title 49. Professional and Vocational Standards, and staff interview, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted and documented a comprehensive resident wound assessment for two of 14 residents reviewed (Residents R6 and R22).
Fire safety inspections
14 fire safety citations on file: 8 on September 18, 2025, 6 on November 15, 2023.
Every fire safety citation14 citations
- F
Have an enclosure around a vertical opening shaft.
K 311 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · September 18, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · September 18, 2025 · Corrected (the home has a date of correction)
- C
Have power receptacles that are properly grounded.
K 912 · September 18, 2025 · Corrected (the home has a date of correction)
- B
Meet other general requirements.
K 200 · September 18, 2025 · Corrected (the home has a date of correction)
- B
Have restrictions on the use of highly flammable decorations.
K 753 · September 18, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · November 15, 2023 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · November 15, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 15, 2023 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · November 15, 2023 · Corrected (the home has a date of correction)
- B
Install corridor and hallway doors that block smoke.
K 363 · November 15, 2023 · Corrected (the home has a date of correction)
- B
Have power receptacles that are properly grounded.
K 912 · November 15, 2023 · Corrected (the home has a date of correction)