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 50 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
38D
9E
1F
Potential for minimal harm
0A
0B
0C
December 11, 2025Standard inspection · 13 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, review of facility policies, facility documentation and interview with staff, it was determined that the facility failed to ensure that hot water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature. This failure placed residents on three of three nursing units at risk of serious injury from a burn and resulted in an Immediate Jeopardy situation. (First floor East, Second floor East and West)
- 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, review facility policies and staff interview, it was determined that the facility failed to maintain a safe, clean and homelike environment in resident care areas for two of three nursing units observed (1st floor East and 2nd floor [NAME] Nursing units). Findings Include:Review of facility policy Physical Environment: Common Areas dated January 2025, revealed, the facility will be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. On December 8, 2025, at 1:25 p.m. unit manager, Employee E8 confirmed that room [ROOM NUMBER]B had no grid on the heating unit and the cover of the heating unit was coming off. On December 9, 2025, at 12:45 p.m. [...]
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on review of facility policy, review of clinical records, and staff and resident interviews it was determined that the facility failed to safeguard medications tor one of 29 residents reviewed (Resident R7). Findings Include: Review of Resident R7's Annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 30, 2025, revealed the resident had a diagnosis of chronic obstructive pulmonary disease (COPD - progressive lung disease that makes it hard to breathe). Continued review of Resident R7's MDS dated [DATE], revealed the resident was cognitively intact. Review of Resident R7's comprehensive care plan revised February 15, 2025, revealed the resident had the potential for inadequate respiratory function. Intervention dated July 26, 2022, indicated to provide medication as ordered. [...]
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that PRN (as needed) orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medications for one of five residents reviewed. (Resident R10). Findings Include:Review of FDA (Food and Drug Administration) (The United States Food and Drug Administration (FDA), a federal agency within the Department of Health and Human Services, protects public health through the regulation of foods, drugs, cosmetics, and medical devices) guidance for Haldol revealed that, HALDOL (haloperidol) is indicated for use in the treatment of schizophrenia. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. [...]
- 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 documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility discharge which occurred Against Medical Advise (AMA), attempts to provide discharge instruction, assess resident's capacity to make decision, attempts to contact the resident's representative, and notify the physician, for 1 of 2 residents reviewed (Residents R166).
- 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 a review of facility documents, observations, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure the resident's care plan was updated and revised to address a resident's diagnosis of legal blindness and required assistance with eating for one of 29 residents reviewed. (Resident R143)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, and staff and resident interviews it was determined that the facility failed to implement physician orders related to high blood sugars for one of 29 residents reviewed (Resident R7).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that tracheostomy equipment was properly maintained for one of one resident receiving tracheostomy care. (Resident R127)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for one of two residents reviewed receiving hemodialysis. (Residents R82). Findings Include:Review of facility policy titled Hemodialysis, undated, states, Dialysis pre and post treatment summaries will be communicated to facility. A review of Resident R82's record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease. On December 9, 2025, at 2:37 p.m., an interview with the Director of Nursing, Employee E2, confirmed that dialysis communication for Resident R82 was requested by the facility. [...]
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on review of clinical records it was determined that the facility failed to timely implement behavioral health interventions for one of five residents reviewed for behavioral/emotional health (Resident R4).
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for 1 of 29 residents. (R45). Findings Include:Review of Facility Policy: Resident Representative/Family Provided Food undated, states Food items provided and considered perishable are to be brought into the dietary department and food will be stored in the designated area which shall be temperature controlled. 3. No food will be held for more than 2 days from the provided date. 4. Food provided will be dated and labeled including use by date not to exceed 2 days. On December 8, 2025, at 1:30 p.m., an interview was conducted with Resident R45, who had a small refrigerator next to his bed. [...]
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to ensuring that hot water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature. This failure placed residents on three of three nursing units at risk of serious injury from a burn and resulted in an Immediate Jeopardy situation. (First floor East, Second floor East and West)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and clinical record reviews, the facility failed to ensure staff followed infection control practices by not wearing a gown during tracheostomy care and incontinence care for one of 29 residents reviewed for tracheostomy care and incontinence care (Resident R127). Findings Include: Review of the facility policy titled Enhanced Barrier Precaution revealed that Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). [...]
November 4, 2025Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on a review of clinical records, facility policies and facility documentation, and interview with staff, it was determined the facility failed to ensure Resident R1 was free of neglect which resulted in actual harm to Resident R1 who was transferred from chair to bed without the use of a mechanical lift and sustained a left humeral fracture for one of five residents reviewed. (Resident R1)
September 4, 2025Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interview and facility documentation, it was determined that the facility failed to report to the State Survey Agency and conduct an investigation related to an allegation of neglect for one of 9 residents reviewed. (Resident R2)
- 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 documentation, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall and to ensure that an air mattress was properly fastened to the bed for two out of nine residents reviewed. (Residents R1 and R8).
- 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 staff interview, it was determined that the facility failed to maintain complete documentation of resident's clinical records for one of 9 resident records reviewed (Resident R9).
May 15, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to provide adequate supervision and failed to maintain an environment free of potential hazards for one resident with elopement risk (Resident R14). One of four residents reviewed. (Resident R1)
April 9, 2025Complaint inspection · 2 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, and interview with staff and residents, it was determined that facility failed to ensure that resident were assisted out of bed as per resident's preference for nine of 69 residents observed (Resident R10, R11, R12, R13, R14, R15, R16, R17, R18)
- 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 interview with residents, it was determined that facility did not provide a clean, comfortable, homelike environment for four of 20 rooms observed (common shower room, Resident R8's room, room#225-B, room [ROOM NUMBER]-A)
January 13, 2025Standard inspection · 11 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 observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.
- 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 review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital and that a resident's representative was made aware of a facility-initiated transfer, for one of four residents reviewed. (Residents R136) Findings Include: Review of nursing notes for Resident R136 dated April 21, 2024, at 11:37 p.m. revealed that the resident had a seizure and was transferred to a local hospital for evaluation at approximately 11:25 a.m. Further review revealed a note, dated July 24, 2024, at 6:27 a.m., which indicated that Resident R136 was admitted to the local hospital for altered mental status on July 23, 2024. [...]
- D
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 interviews with staff, it was determined that the facility failed provide appropriate bed hold notice to a resident's representative of a facility-initiated transfer to the hospital for one of four residents reviewed related to transfers (Resident R136).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to restraints for two of 34 records reviewed (Residents R9, R38).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to update Pennsylvania Pre-admission Screening Resident Review (PASRR) of one resident with a new diagnosis of a serious mental disorder, out of 34 sampled residents reviewed (Residents R 103).
- 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 observation, clinical record review and interview with staff and residents, it was determined that the facility did not develop a comprehensive care plan related to dementia, smoking, and pain management for 3 of 34 records reviewed (Residents R7, R28, R155).
- 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 interview with staff, it was determined that the facility did not ensure that care plans were updated in a timely manner for one of 34 records reviewed related to hospice (Resident R31).
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on review of personnel records and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on closed clinical record review, and interviews with staff, it was determined that the facility failed to ensure that controlled medications were disposed in a timely manner for one of 3 closed records reviewed (Resident R162).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Transmission Based Precautions for one of 34 residents reviewed ((Resident R113).
June 11, 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 observation, a review of clinical records, review of facility documentation and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans regarding preventing a reinfestation of lice for one of ten residents reviewed. (Resident R2).
April 5, 2024Standard inspection · 11 citations
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations of the physical environment, reviews of the pest control operators' service, reports and contract and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on review of facility documentation, observation, and staff interview, it was determined that the facility failed to ensure that food was prepared appropriately for nine of nine residents on a pureed diet (Residents R52, R125, R4, R113, R445, R34, R55, R66, and R87). Findings Include: Review of undated facility documentation Dysphagia Level 1/Pureed Diet revealed the consistency of pureed foods should be smooth and thick enough to mound on the plate, and similar in consistency to that of pudding. Review of facility documentation dated April 5, 2024, revealed the following nine residents were ordered a pureed diet: Residents R52, R125, R4, R113, R445, R34, R55, R66, and R87. Observations on April 2, 2024, at 12:08 p.m. revealed Resident R52 was having lunch in the dining room. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection prevention and control program related to infection surveillance, antibiotic usage and isolation precautions for four of four residents reviewed for antibiotics (Residents R45, R33, R124 and R15).
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program that included antibiotic use protocols and systems for monitoring antibiotic use, for four of four residents reviewed for antibiotics (Residents R45, R33, R124 and R15).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on staff interviews, observations, and record reviewed, it was determined that the facility failed to ensure proper accommodation of needs for one of seven residents reviewed regarding appropriate wheelchair size. (Resident R47)
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that advanced directives were accurately reflected in residents' records for one of 35 residents reviewed (Resident R45).
- 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 observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, comfortable and homelike environment on one of three nursing units reviewed (Two [NAME] unit).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one incident during a resident incontinence care for one of 32 residents reviewed. (Resident R 442).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, review of facility policy, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide nail care for two of eight residents reviewed related to activities of daily living (Residents R45 and R70).
- 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 for two of two nurse aides reviewed as required (Employees E28 and E29). Findings Include: Review of undated facility documentation, Active Employees Over 1 Year, revealed that Employee E28 was hired by the facility as a nurse aide on July 12, 2022. Continued review revealed that Employee E29 was hired by the facility as a nurse aide on August 3, 2009. Annual performance reviews were requested for Employees E28 and E29. Interview on April 4, 2024, at 3:00 p.m. with the Nursing Home Administrator, Employee E1, revealed annual performance reviews were not completed for Nurse Aides, Employee E28 and E29. 28 Pa. Code 201.19(2) Personnel policies and procedures
- 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 facility policy and observation, it was determined that the facility failed to ensure one of two medication carts observed remained locked on a secured nursing unit. (Second floor0.
December 11, 2023Complaint inspection · 4 citations
- E
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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the Facility's Assessment included a risk assessment for each resident environment to remain free of accident hazards for one of one nursing units observed (Second Floor Behavioral Health Nursing Unit) and one of one resident's reviewed (Resident R1).
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on clinical record review, observation and staff interviews, it was determined that the facility failed to prevent involuntary seclusion for four of four residents reviewed (Resident R1, R2, R3, and R4).
- 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 included non-pharmacological interventions for a resident receiving PRN (as needed) psychotropic medications for one of four residents reviewed (Resident R1).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on review clinical records and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of four residents reviewed (Resident R1).
October 25, 2023Complaint inspection · 3 citations
- 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 the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood after a selected resident was transferred to the hospital for one of nine residents reviewed. (Resident R1) Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R1 dated September 8, 2023, revealed that the resident had a BIMS score of 10 which indicated that the cognitive status was moderately impaired. Review of nursing note for Resident R1 dated October 13, 2023, revealed that the resident was transported out to the hospital related to an unwitnessed fall. [...]
- D
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 ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of nine residents reviewed. (Resident R1)
- 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 interviews with staff, it was determined that the facility failed to update and revise a resident's care plan after multiple falls one of nine residents reviewed (Resident R1).
Fire safety inspections
8 fire safety citations on file: 5 on December 11, 2025, 1 on January 13, 2025, 2 on April 5, 2024.
Every fire safety citation8 citations
- C
Create arrangements with other facilities to receive patients.
E 25 · December 11, 2025 · Not yet corrected
- C
List the names and contact information of those in the facility.
E 30 · December 11, 2025 · Not yet corrected
- C
Establish emergency prep training and testing.
E 36 · December 11, 2025 · Not yet corrected
- C
Establish staff and initial training requirements.
E 37 · December 11, 2025 · Not yet corrected
- C
Conduct testing and exercise requirements.
E 39 · December 11, 2025 · Not yet corrected
- C
Establish staff and initial training requirements.
E 37 · January 13, 2025 · Corrected (the home has a date of correction)
- C
Create arrangements with other facilities to receive patients.
E 25 · April 5, 2024 · Corrected (the home has a date of correction)
- C
Provide primary/alternate means for communication.
E 32 · April 5, 2024 · Corrected (the home has a date of correction)