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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
23D
6E
1F
Potential for minimal harm
0A
0B
1C
May 20, 2026Standard inspection, Complaint inspection · 4 citations
- E
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, observation, and interview with staff it was determined that the facility failed to store food in accordance with standards for food service safety in two of two nourishment rooms observed (ground and 1st floor nursing units).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, interview, and staff documentation, the facility failed to ensure one of two residents reviewed resident received necessary care and services to prevent recurrent hypoglycemic events, failed to implement and follow physician/provider orders related to insulin management, failed to adequately monitor and reassess the resident following hypoglycemic episodes, and failed to accurately document interventions and resident response, resulting in repeated symptomatic hypoglycemia requiring emergency hospital transfer. (Resident R109) Review of facility policy management of Hypoglycemia undated revealed that residents with hypoglycemia must be closely monitored for symptoms such as weakness, sweating, confusion, dizziness, behavioral changes, or decreased consciousness. [...]
- 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, observations, and staff and resident interviews it was determined that the facility failed to ensure adequate supervision for two of two residents (Resident R104 and R58). Findings Include: Review of facility policy titled, Smoking Policy-Residents with a revision date of October 2023 states, Policy Statement- this facility has established and maintains safe resident smoking practices. Further review of the policy states, 8. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption b. method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etc.) c. desire to quit smoking and d. ability to smoke safely with or without supervision (per completed Smoking Evaluation). [...]
- C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process.
May 16, 2025Standard inspection, Complaint inspection · 7 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical documentation and staff interviews, it was determined the facility failed to ensure adequate supervision during care by ensuring two staff were available for one of two residents reviewed (Resident R56). This failure resulted in actual harm to Resident R56 who fell out of bed and sustained a compound fracture of the right femur (hip). This deficiency was identified as past non-compliance.
- 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 documentation, review of clinical records, and staff interview it was determined that the facility failed to develop and implement a baseline care plan related to a pressure ulcer for one of two new admissions reviewed (Resident R47). Findings Include: Review of facility policy Care Plans - Baseline revealed a baseline plan of care to meet the resident's immediate health/safety needs is developed for each resident within 48 hours of admission. [...]
- 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 and clinical record review, it was determined that the facility did not ensure the comprehensive care plan was implemented related to communication for one of 18 residents reviewed (Resident R46).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that weights were monitored for two of 18 residents reviewed (Resident R23, R29)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent for one of three residents observed during medication administration (Residents R6).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to be free of significant medication error for one of three residents (Residents R6).
- 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 observations and staff interviews, it was determined that facility did not ensure that opened medications were properly labeled with the date that the medication was opened for two of three medication carts reviewed and one of one medication room reviewed. (Upper Level Med room, Lower Level South Med Cart, Lower Level North Med Cart).
April 3, 2025Complaint inspection · 3 citations
- 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 and facility provided documentation, it was determined facility failed to develop a care plan related to urinary track infection for one of nine residents reviewed (Resident R1)
- D
Honor each resident's preferences, choices, values and beliefs.
Inspectors wroteBased on interview with resident and review of facility provided documentation, it was determined that facility failed to ensure that toiletries were provided upon admission to the facility for one of three residents reviewed. ( Resident R4)
- D
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 interview with residents and review of facility provided documentation, it was determined that facility failed to ensure that call bells were responded to for three of nine residents reviewed ( Residents R2, R3, and R4)
March 12, 2025Complaint inspection · 2 citations
- E
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 observations and interviews with residents and staff, it was determined that the facility failed to provide a comfortable environment due to clogged bathroom sinks in two of the four nursing units observed (Upper-Level South and North Nursing Units).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review, facility policy, resident and staff interview, it was determined that the facility failed to ensure complete and accurate medication administration for one of 2 residents reviewed (Resident R2).
January 22, 2025Complaint inspection · 1 citation
- 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 interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan related to wound care for one of 6 residents observed (Resident R1).
December 11, 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 interviews, review of facility documentation, and review of clinical records, it was determined that the facility failed to ensure that appealing food options were available for residents for 1 out of 5 residents reviewed (Resident R1).
November 25, 2024Complaint inspection · 1 citation
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on review of clinical records, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program related to mice infestation on two of four nursing units (LL South Wing, and LL North Wing).
October 2, 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, clinical record review, and staff interview, it was determined that the facility failed to ensure that Resident R1 was free of neglect during a transfer via mechanical lift which resulted in actual harm to Resident R1 who was transfered with the assistance of one staff member, the tightening of the sling pad and sustaining a fracture of the fourth lumbar vertebra, compresion fracture of the second lumbar vertebra, multiple fracture of ribs to the left side, and compression fracture of the third vertebra for one of three residents reviewed. (Resident R1) This deficiency was cited as past non-compliance.
- 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 and documents, clinical record review, and staff interview, it was determined that the facility failed to ensure the proper transfer of Resident R1 via mechanical lift with the assistance of two staff, which resulted in actual harm to Resident R1 with the tightening of the sling pad, sustaining fracture of the fourth lumbar vertebra, compresion fracture of the second lumbar vertebra, multiple fracture of ribs to the left side, and a compression fracture of the third vertebra. (Resident R1) This deficiency is cited as past non-compliance.
July 22, 2024Standard inspection, Complaint inspection · 8 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 observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.
- E
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 resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for 8 out of 18 residents reviewed. (Residents R70, R87, R51, R65, R141, R75, R23 and R45). Findings Include: An initial tour of the facility was taken on July 16, 2024, at 10:15 a.m. of Upper Level North units revealed the following: Interview with Resident R70 revealed that she was unable to call her family stating that her phone has not been working since she was admitted on [DATE]. Observation of Resident R70's phone revealed that it was plugged into the wall, but did not have a dial tone or light up. Interview with Resident R87 revealed that her phone did not work either. Observation of Resident R70's phone revealed that it was plugged into the wall, but did not have a dial tone or light up. [...]
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that the resident's clinical record included complete and accurate documentation that residents were provided with the right to participate in his/her care plan meetings for 6 out of 6 residents reviewed (Resident R63, R18, R30, R1 and R3).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that physician orders were followed for the administration of pain medication for one out of 21 residents records reviewed (Resident R5).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, review of facility policy and staff interviews, it was determined that the facility failed to accurately record resident's weight, and failed to monitor, assess and implement interventions in a timely manner for a resident with significant weight loss for 1 of 21 records reviewed. (Resident R76)
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews of nurse aides as required.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on a review of clinical records, review of facility policy and staff interviews, it was determined that the facility did not maintain complete and accurate clinical records related to enteral feeding volume documentation for 2 of 21 records reviewed (Resident R64 and Resident R191).
- 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 staff interviews, the review of the clinical record and facility documentation, it was determined that the facility failed to ensure that a communication process was utilized for communication between the facility and the hospice care agencies for 1 out of 1 resident review receiving hospice care (Resident R41).
May 10, 2024Complaint inspection · 2 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 facility policies, clinical record review and interviews with staff, it was determined that the facility failed [NAME] ensure that medications were administered at the correct time as ordered by the physician for one of 5 residents reviewed (Residents R1).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on the observation, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by documenting on the Medication Administration Record that medications were administered to a resident who was at dialysis treatment for one of 5 clinical records reviewed. (Resident R2).
March 13, 2024Complaint inspection · 1 citation
- 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, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of five residents reviewed (Resident CL1).
December 6, 2023Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on the review of clinical records, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that complete and accurate clinical records were maintained for one out of three residents reviewed (Resident R1).
October 13, 2023Complaint inspection · 1 citation
- E
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that personal belongings were accounted and release upon discharged for one out of 22 residents reviewed.
Fire safety inspections
21 fire safety citations on file: 10 on May 20, 2026, 8 on May 16, 2025, 3 on July 22, 2024.
Every fire safety citation21 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 20, 2026 · deficient, provider has
- E
Install a two-hour-resistant firewall separation.
K 133 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 20, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 20, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 16, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 16, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · July 22, 2024 · Waiver
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · July 22, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 22, 2024 · Corrected (the home has a date of correction)