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 56 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
23E
0F
Potential for minimal harm
0A
0B
0C
June 30, 2026Complaint 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 policies, clinical records, observations and staff interviews, it was determined that the facility failed to implement interventions in a resident's care plan to prevent a wandering resident from entering other's rooms for six of 19 residents reviewed (Residents 13, 14, 15, 16, 17, 18).
August 7, 2025Standard inspection · 8 citations
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for 11 of 65 residents reviewed (Residents 1, 9, 30, 39, 51, 85, 108, 115, 180, 222, 238).
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 15 of 65 residents reviewed (Residents 10, 22, 43, 71, 72, 75, 77, 83, 108, 112, 115, 124, 150, 190, 199).
- 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, clinical records, and the Minimum Data Set validation report, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for 3 of 65 residents reviewed (Residents 26, 83, 218).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for six of 65 residents reviewed (Residents 3, 5, 8, 75, 112, 186).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 65 residents reviewed (Residents 51, 72, 180).
- 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 staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 65 residents reviewed (Resident 83).
- 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 manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to date an opened multidose vial of tuberculin solution (used to detect tuberculosis infection) in one of two medication storage area refrigerators reviewed (Unit D2). The facility's policy regarding medication storage, dated July 17, 2025, indicated that it is the policy of this facility to ensure all medications housed on their premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. Manufacturer's instructions for Aplisol solution, dated November 2013, indicated that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 65 residents reviewed (Resident 5).
June 27, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 11 residents reviewed (Resident 2).
March 5, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of five residents reviewed (Resident 1).
November 18, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for handling linen while providing care for two of 11 residents reviewed (Residents 10, 11).
August 28, 2024Standard inspection · 20 citations
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for four of 57 residents reviewed (Residents 32, 128, 204, 225).
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for four of 57 residents reviewed (Residents 33, 147, 157, 159).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for eight of 57 residents reviewed (Residents 1, 3, 143, 148, 171, 182, 192, 194).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for two of 57 residents reviewed (Residents 2, 143).
- E
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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that enteral feedings (feeding through a tube inserted directly into the stomach) were administered in accordance with physician's orders and failed to ensure that residents who were receiving enteral feedings received appropriate treatment and services to prevent complications for two of 57 residents reviewed (Residents 20, 56). A facility policy for tube feeding, dated May 8, 2024, revealed that it is the policy and procedure to provide nourishment to the resident who is unable to obtain nourishment orally. The procedure for administering tube feeding includes to check for residual (the amount of gastric fluid in the stomach between feedings) by pulling back no more than 150 cubic centimeters (cc). Note the amount of residual if any. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for cleaning durable medical equipment for two of 57 residents reviewed (Residents 47, 133), and for providing care for five of 57 residents reviewed (Residents 101, 152, 163, 184, 204).
- 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 interviews with residents and staff, as well as observations, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as eating in the dining room with other residents, for nine of 57 residents reviewed (Residents 70, 72, 79, 125, 149, 151, 157, 162, 164).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage, or failed to provide 48-hour advanced notice, for two 57 residents reviewed (Residents 201, 228).
- D
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 reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative, in writing, regarding the reason for hospitalization for six of 57 residents reviewed (Residents 85, 96, 157, 171, 192, 218).
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive significant change Minimum Data Set assessments were completed in the required time frame for two of 57 residents reviewed (Residents 96, 171).
- 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for one of 57 residents reviewed (Resident 182).
- 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 57 residents reviewed (Residents 125, 191).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical records and the facility's investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free from falls as possible and failed to develop and implement interventions to prevent falls for one of 57 residents reviewed (Resident 165) who had a history of falling.
- 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 ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 57 residents reviewed (Resident 46).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on a list of nurse aides provided by the facility and their personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on the hire dates for three of three nurse aides reviewed (Nurse Aide 1, Nurse Aide 2, Nurse Aide 3).
- 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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that controlled medications (drugs with the potential to be abused) were properly secured in the medication cart for one of 57 residents reviewed (Resident 14) and failed to ensure that medications were appropriately labeled for one of 57 residents reviewed (Resident 47). The facility's policy for medication storage dated May 8, 2024, included that all controlled drugs are stored under double-lock and key. Physician's orders for Resident 14, dated August 25, 2024, included an order to give the resident 0.5 milligrams (mg) of Clonazepam every eight hours for anxiety. Observations of the [NAME] Hall medication cart on August 27, 2024, at 8:39 a.m. [...]
- 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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions and failed to ensure that dietary staff wore appropriate hair and beard coverings in the kitchen.
- 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 clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 57 residents reviewed (Resident 225).
- 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain the required information from the contracted hospice provider for one of 57 residents reviewed (Resident 128).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
August 7, 2024Complaint inspection · 3 citations
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of five residents reviewed (Resident 2).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act, job descriptions, and clinical records, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of five residents reviewed (Resident 2).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen was provided as ordered by the physician for one of five residents reviewed (Resident 1).
May 15, 2024Complaint 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 policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner for one of six residents reviewed (Resident 2).
April 16, 2024Complaint inspection · 5 citations
- E
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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for two of nine residents reviewed (Residents 3, 7).
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dialysis residents had an active physician's order to attend dialysis and failed to obtain physician's orders for the care and monitoring of dialysis sites for one of nine residents reviewed (Resident 7).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of nine residents reviewed (Residents 3, 7).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide care for wounds in accordance with professional standards of practice by failing to follow recommendations from wound consultations for one of nine residents reviewed (Resident 3), and failed to ensure that the physician was notified about elevated blood sugar results as ordered for one of nine residents reviewed (Resident 7).
- 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 policy, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for two of nine residents reviewed (Residents 2, 9).
December 22, 2023Complaint inspection · 1 citation
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of nine residents reviewed (Resident 2).
October 26, 2023Standard inspection, Complaint inspection · 14 citations
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for seven of 58 residents reviewed (Residents 51, 80, 156, 168, 170, 183, 191 ).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for nine of 58 residents reviewed (Residents 48, 57, 79, 113, 117, 126, 148, 155, 192).
- E
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 that included specific and individualized interventions to address care needs for four of 58 residents reviewed (Resident 5, 45, 67, 150).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding notification of the physician for blood sugar results were followed for one of 58 residents reviewed (Resident 48).
- 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 package inserts, as well as observations and staff interviews, it was determined that the facility failed to discard expired medical supplies in one out of three medication rooms reviewed (D1) and one out of one treatment rooms reviewed.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on review of facility's policies, observations, and resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures.
- E
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 interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on review of manufacturer's instructions and information provided by the facility, as well as observations and resident and staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program for the walk-in-freezer and failed to maintain the dish machine in proper working condition in the Main Kitchen, taking away the residents' right to have a homelike environment.
- 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 reviews and staff interviews, it was determined that the facility failed to ensure that residents' baseline care plans included information regarding their immediate care needs for one of 58 residents reviewed (Resident 195).
- 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three of 58 residents reviewed (Residents 31, 145, 152).
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on review of manufacturer's instructions and clinical records, as well as resident, family, and staff interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate hearing for one of 58 residents reviewed (Resident 92).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate that was less than five percent.
- 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 clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 58 residents reviewed (Resident 45).
Fire safety inspections
22 fire safety citations on file: 3 on August 7, 2025, 12 on August 28, 2024, 7 on October 26, 2023.
Every fire safety citation22 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · August 28, 2024 · 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 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 28, 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 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 28, 2024 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · August 28, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · October 26, 2023 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · October 26, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 26, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 26, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 26, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 26, 2023 · 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 · October 26, 2023 · Corrected (the home has a date of correction)