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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
6D
2E
1F
Potential for minimal harm
0A
2B
0C
June 16, 2026Complaint 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 eight residents reviewed for medication administration (Resident R1).
January 16, 2026Complaint inspection · 2 citations
- 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 and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect for one of four residents (Resident R1). This was identified as past non-compliance.
- 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 policies and documents, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls for one of four residents (Resident R1). This was identified as past non-compliance.
July 17, 2025Complaint inspection · 2 citations
- F
Keep all essential equipment working safely.
Inspectors wroteBased on facility document review and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition on five of five nursing units (2A, 3A, 3B, 4A, and 4B). Review of facility submitted information dated 7/16/25, indicated that on 7/15/25, At 7:11pm, During a scheduled facility power outage, the maglock (electrified magnetic locking mechanism) door batteries became disengaged. While monitoring CCTV (closed-circuit television, a type of video surveillance system), Security saw resident enter the stairwell on unit 4A. Resident was identified as [Resident R1]. Security witnessed on camera her carefully safely walk down the stairwell and exit on unit 2A. Total Time 2 mins and 20 seconds. Nursing Supervisor immediately notified by Security and met resident on unit 2A. Resident returned to the unit safely. Resident had no injury. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of 41 residents (Resident R1). Review of the facility policy Elopement - Missing Resident dated 1/8/25, indicated the facility will provide to each resident adequate monitoring and interventions to maintain safety. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/30/25, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and a seizure disorder. Review of Section E: Behavior indicated Resident R1 had displayed wandering behaviors. [...]
September 26, 2024Standard inspection · 5 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, resident clinical records, documentation provided by the facility, facility investigation, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect, which resulted in actual harm as evidenced by a left distal femur (thigh bone closest to the knee bone) fracture for one of three residents (Resident R91) and a head injury for one of three residents (Resident R3).
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls and an injury, resulting in actual harm of a leg fracture for one of three residents reviewed (Resident R91) and a head laceration for one of three residents (Resident R3).
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, review of facility incident/accident reports, clinical records, and staff interviews, it was determined that the facility failed to identify and/or investigate potential abuse and/or neglect for one of three residents (Resident R3).
- B
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on abuse, neglect, and exploitation prevention for two of ten staff members (Employee E3 and E4).
- B
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for two of ten staff members (Employee E1 and E2).
September 28, 2023Standard inspection · 2 citations
- 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 notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven Residents (Residents R53, R64, R71, and R76).
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R20).
October 28, 2022Standard inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policy, employee personnel records, grievance and abuse investigation documents, reports submitted to the State field office, resident interview and staff interview it was determined that the facility failed to make certain that all allegations of verbal abuse are reported to the State Agency as required for one of five residents (Resident R96).
Fire safety inspections
13 fire safety citations on file: 4 on September 26, 2024, 5 on September 28, 2023, 4 on October 28, 2022.
Every fire safety citation13 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 26, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 26, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 26, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · September 26, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 28, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 28, 2023 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 28, 2023 · Corrected (the home has a date of correction)
- D
Ensure medical gas and vacuum systems have documented maintenance programs.
K 907 · September 28, 2023 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · September 28, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 28, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 28, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 28, 2022 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · October 28, 2022 · Corrected (the home has a date of correction)