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 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
37D
5E
3F
Potential for minimal harm
0A
2B
1C
April 17, 2026Standard inspection, Complaint inspection · 13 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 review and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to notify the resident and/or resident's representative(s) of transfer(s), and failed to notify a representative of the Office of the Long-Term Care Ombudsman, including the reasons for the moves, in writing upon transfer for six of six residents who were transferred out of the facility. (Residents 2, 7, 14, 42, 149, and 151)
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on facility policy review, resident group interview, a review of facility resident council meeting minutes and grievances, and staff interview, it was determined that the facility failed to address grievances voiced by residents.
- 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, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of five nursing units. ([NAME] and [NAME] units)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 31 sampled residents. (Resident 139)
- 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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed the individual resident's needs as identified in the comprehensive assessment for one of 31 sampled residents. (Resident 13)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for one of 31 sampled residents. (Resident 1)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for three of 31 sampled residents. (Residents 4, 8, and 139)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on facility policy review and clinical record review it was determined that the facility failed to attempt and document non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for two of 31 sampled residents. (Resident 6, 96)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to provide appropriate dialysis treatment for one of 31 sampled residents (Resident 10).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to assess residents with a diagnosis of post-traumatic stress disorder (PTSD) and develop and implement an individualized person-centered care plan to render trauma informed care for one of 31 sampled residents. (Resident 1)
- D
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 clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two of 31 sampled residents. (Residents 6 and 12)
- D
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 a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually, including training for dementia management, resident abuse prevention, and identified performance weaknesses for two of two nurse aides reviewed (NA 1 and NA 2).
February 4, 2026Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to report an alleged violation of potential neglect for one of six sampled residents. (Resident 1)
- 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 clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of six sampled residents. (Resident 1)
May 27, 2025Complaint inspection · 1 citation
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on resident interview, review of facility documentation, and results of a test tray audit, it was determined that the facility failed to provide food and beverages that were at an appetizing temperature on one of five nursing units. ([NAME] unit)
March 26, 2025Standard inspection, Complaint inspection · 15 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 review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on a review of facility policy, review of facility documentation, and staff interview, it was determined that the facility failed to perform infection surveillance in accordance with facility policy.
- E
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 interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure that a call bell was answered in a timely manner for one of 29 sampled residents. (Resident 16) In addition, the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to one of 29 sampled residents. (Resident 47)
- 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 clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that a resident received care from staff as she preferred in order to attend activities of her choice for one of 29 sampled residents. (Resident 4)
- 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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 29 sampled residents. (Residents 51 and 141)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to provide a restorative ambulation program as recommended by physical therapy for one of one sampled resident who was recommended for a restorative ambulation program. (Resident 94)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to implement physician's orders for five of 29 sampled residents. (Residents 37, 51, 119, 141, 355) In addition, the facility failed to obtain a physician order for a compression stocking and a compression wrap for one of one sampled resident. (Resident 355)
- 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 clinical record review and observation, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of five sampled residents at risk for limited range of motion. (Resident 101)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 44) In addition, the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of two sampled residents at risk for bladder function loss. (Resident 144)
- 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 a review of facility policy and observation, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication or treatment cart on one of six nursing units. ([NAME] nursing unit)
- 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 clinical record review and observation, it was determined that the facility failed to ensure that residents were served preferred food items on their meal trays for three of 29 residents. (Residents 94, 96 and 118)
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to consistently implement an antibiotic stewardship program and maintain a system to effectively monitor antibiotic usage for one of two residents receiving antibiotics. (Resident 355)
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to offer pneumococcal disease vaccines in accordance with facility policy to five of 29 residents whose vaccines were reviewed. (Residents 41, 51, 56, 80, 137)
- B
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of five nursing units. ([NAME] unit)
December 20, 2024Complaint inspection · 3 citations
- 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 clinical record review and policy review, it was determined that the facility failed to ensure that the baseline care plan summary was provided to the resident or representative for three of six sampled residents. (Residents 2, 3, 4)
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to review the care plan within seven days after the completion of the comprehensive assessment for three of six sampled residents. (Residents 1, 5, 6)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's order were implemented for one of six sampled residents. (Resident 1)
August 21, 2024Complaint inspection · 2 citations
- 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 review, clinical record review, observation and interview, it was determined that the facility failed to provide care and services in a manner respectful of each resident's dignity and preferences to promote the quality of life for one of five sampled residents. (Resident 1)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of five sampled residents. (Resident 1)
April 12, 2024Standard inspection, Complaint inspection · 11 citations
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for seven of 29 sampled residents. (Residents 5, 27, 46, 90, 105, 115, and 135)
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for five of 29 sampled residents. (Residents 27, 34, 44, 63, 76)
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, facility policy review, and staff interview, it was determined that the facility failed to store food in a sanitary manner on two of three resident nourishment rooms. ([NAME] and [NAME])
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for three of 29 sampled residents. (Residents 28, 63, 90)
- 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 clinical record review and staff interview, it was determined that the facility failed to develop a care plan and interventions to meet each residents' needs as identified in the comprehensive assessment for one of 29 sampled residents. (Resident 1)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on a review of facility policy observation, and resident and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of quality as defined by the PA Code Title 49, Professional and Vocational Standards for one of 29 sampled residents. (Resident 145)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess and document the status of wounds for three of seven sampled residents with wounds. (Residents 17, 46, 145)
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD) for one of 29 sampled residents. (Resident 145)
- D
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 clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two of 29 sampled residents. (Residents 63, 115)
- C
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 clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative(s) of transfer and the reasons for the move in writing for seven of seven sampled residents who were transferred to the hospital. (Residents 1, 15, 17, 44, 46, 87, 115 )
- B
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 clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident, responsible party, or legal representative at the time of transfer for six of seven sampled residents who were transferred to the hospital. (Residents 1, 15, 17, 46, 87, 115)
February 20, 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 clinical record review and staff interview, it was determined that the facility failed to ensure that each resident was offered medication as prescribed by the physician for three of six sampled residents. (Residents 1, 2, 4)
Fire safety inspections
11 fire safety citations on file: 2 on March 26, 2025, 6 on April 12, 2024, 3 on May 19, 2023.
Every fire safety citation11 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · March 26, 2025 · Corrected (the home has a date of correction)
- 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 · April 12, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · 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)
- C
Properly provide smoke detection systems in areas open to corridors.
K 347 · April 12, 2024 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 12, 2024 · Corrected (the home has a date of correction)
- C
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · April 12, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 19, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 19, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 19, 2023 · Corrected (the home has a date of correction)