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 53 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
3G
1H
0I
Potential for more than minimal harm
24D
22E
2F
Potential for minimal harm
0A
0B
0C
July 23, 2026Complaint inspection · 2 citations
- 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 a review of clinical records, physician orders, facility documentation, and interviews with staff and the resident's family, it was determined the facility failed to honor and implement the resident representative's end-of-life treatment decisions by failing to facilitate and implement requested hospice services after the resident representative authorized hospice care and requested a change in the resident's Pennsylvania Orders for Life-Sustaining Treatment (POLST) order, for one of three residents reviewed (Resident CR1).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on a review of clinical records, facility policy, dental consultation records, documentation from the dental provider, and staff and resident representative interviews, it was determined the facility failed to assist a resident in obtaining timely medically necessary dental services after a fractured tooth requiring extraction was identified, for one of 13 residents reviewed (Resident CR1) for dental services.
January 12, 2026Complaint inspection · 1 citation
- 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 records, facility policy, observations, facility-provided investigative documentation, security camera evidence, and resident and staff interviews, it was determined that the facility failed to ensure appropriate supervision and implementation of safety interventions to protect a resident from accident hazards (medications) and elopement from the facility. This failure resulted in actual physical harm for one out of 10 residents sampled (Resident 1).
March 27, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that one resident (Resident 2) out of 15 sampled were free from physical abuse perpetrated by another resident (Resident 1).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on a review of the facility's Plan of Correction from the survey ending February 7, 2025, the results of the revisit survey conducted on March 27, 2025, clinical record review, facility-submitted documentation, and staff interview, it was determined that the facility failed to implement and sustain corrective actions through its Quality Assurance and Performance Improvement (QAPI) program to prevent the recurrence of deficiencies related to abuse prevention for one resident out of 15 residents reviewed. (Resident 1)
February 7, 2025Standard inspection, Complaint inspection · 6 citations
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on review of select facility policy, facility grievance forms, and resident, family and staff interviews, it was determined the facility failed to make ongoing efforts to resolve grievances and the provision of timely follow-up with residents and/or their representative regarding the status update on the resolution progress of a grievance for three of seven residents reviewed (Residents 107, 15 and 4).
- E
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 the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that two residents (Residents 366 and 52) out of 35 sampled were free from physical abuse perpetrated by another resident (Resident 180).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of two residents out of 35 sampled (Resident 179 and Resident 159).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, select facility investigative reports, and resident and staff interviews, it was determined the facility failed to implement effective safety measures to prevent an injury during transfer for one out of the 35 sampled residents (Resident 157).
- 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, select facility investigative reports, and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, in accordance with professional standards of practice for one (1) of 35 sampled residents (Resident 266).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on a review of select facility policy and clinical records and staff interviews, it was determined the facility failed to offer and/or provide the influenza immunization, unless the immunization was medically contraindicated or the resident had already been immunized, to one resident out of five residents reviewed for administration of the flu vaccine. (Resident 110).
January 3, 2025Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of clinical records, select facility policy, and staff interview it was determined the facility failed to monitor and evaluate weight and hydration requirements of a resident to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of six sampled (Resident A1).
July 10, 2024Complaint inspection · 5 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff, residents and resident representatives, it was determined that the facility failed to ensure that one resident was free from sexual abuse and resultant psychosocial harm (Resident 16) and that one resident (Resident 106) was free from physical abuse out of 11 residents sampled for abuse prohibition.
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff, residents, and resident representatives, it was determined that the facility failed to implement their established procedures for responding to an incident of sexual abuse of one resident (Resident 16) perpetrated by another resident (Resident 91) out of 11 residents reviewed for abuse prohibition.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, review of select facility incident reports and clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision and maintain an environment free of accident hazards to prevent a minor injury (a cut to the thumb) sustained by one of 11 sampled residents (Resident 65).
- E
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 select facility policy and staff interview, it was determined the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to conduct a thorough resident assessment of residents following an incident of sexual abuse involving two out of 11 residents reviewed (Resident 16 and Resident 91)
- 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 plan of correction from the survey of April 19, 2024, and the findings of the survey ending July 10, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent a continued quality deficiency related to abuse prohibition to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies.
May 31, 2024Complaint inspection · 6 citations
- K
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 select facility policy, observations, and staff and resident interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement by one resident (Resident 181) out of 14 sampled residents, placing the 65 residents out of 238 residents residing in the facility, identified at risk for elopement, including Resident 142, in immediate jeopardy to their health and safety.
- G
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on review of clinical records, the facility's diet manual and select facility incident reports, and staff interviews, it was determined that the facility failed to ensure that a resident identified with swallowing difficulties was consistently served food in a form to meet the resident's individual needs, which caused a choking incident and aspiration (when food, drink, or foreign objects are breathed into the lungs) requiring hospitalization of one of 14 residents reviewed (Resident 196). Findings Include: Review of Resident 196's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing). Review of resident's current care plan dated March 5, 2024, and in effect on April 21, 2024, revealed the resident required the assistance of one staff person with eating. [...]
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on a review of clinical records, select facility policies, investigate reports, and employee job descriptions it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to monitor resident whereabouts and prevent an elopement for one out of 16 sampled residents (Resident 181 ).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review clinical records, and resident and staff interview it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as reported by two residents out of 14 residents sampled (Residents 14 and Anonymous Resident 1).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on a review of clinical records and select incident reports, observation, and staff interview, it was determined that the facility failed to provide dependent residents with the necessary feeding assistance to promote safe swallowing for one of 14 residents sampled (Resident 196).
- D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on a review of clinical records and select facility policy, and resident and staff interview, it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack for one resident out of 14 sampled (Resident 14).
April 19, 2024Standard inspection · 12 citations
- H
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 clinical records, the facility's abuse prohibition policy, and select investigative reports, and staff interviews, it was determined that the facility failed to ensure that six residents (Residents 212, 93, 203, 178, 487, and 152) were free from physical abuse perpetrated by other residents (Residents 3, 188, 225, 212, 221, 213, and 56) out of 41 residents sampled for abuse prevention, which resulted in serious harm and injury to one resident, a fractured leg and hip (Resident 203).
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and one of five resident pantries.
- 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 staff interview, it was determined that the facility failed to maintain a clean and orderly environment on four of five resident units (Nursing Unit 2, 3, 4, 5 in the blue and white buildings)
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observations, review of select facility policy and staff interviews, it was determined that the facility failed to make information and forms accessible regarding the facility's grievance/complaint process and the residents' rights to file a grievance anonymously in prominent locations on four of seven floors in the facility (blue and white buildings).
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on select facility policy and clinical records, observations, and staff interview it was determined that the facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for six out of 35 sampled residents (Resident 8, 26, 48, 59, 64 and 124).
- E
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Inspectors wroteBased on observations, a review of clinical records and facility investigations, and staff interview, it was determined that the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by three residents out of 35 sampled (Residents 213, 214, and 188).
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observations, a review of select facility policy, clinical records and reports, and staff interviews, it was determined that the facility failed to develop and/or implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and highest practicable physical and mental well-being for four residents out of 35 sampled (Residents 138, 213, 221 and 225).
- 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 staff interviews and a review of the facility's assessment and the medical, psychiatric, and mental health conditions of the resident census it was determined that the facility failed to conduct and document a facility wide assessment, which identified the specific resources necessary to care for its specific resident population.
- 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 review of clinical records and staff and resident interview, it was determined that the facility failed to incorporate preferred resident schedules into the residents' daily routine and to allow resident to make choices about aspects of their life that were important to them as evidenced by three of 35 sampled residents (Resident 19, 26 and 64).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on a review of clinical records 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 for one out of 35 residents reviewed (Resident 29).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on a review of clinical records and staff interviews it was determined that the facility failed to ensure that residents were free from significant medication errors for one resident out of (Resident 103) out of 35 sampled.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on a review of clinical records, select facility policies, investigate reports, and employee job descriptions it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to prevent physical abuse of six out of 41 sampled residents (Residents 212, 93, 203, 178, 487, and 213).
March 20, 2024Complaint inspection · 2 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review clinical records, facility provided documentation, grievances lodged with the facility, and the minutes from Resident Council meetings, and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as reported by 15 residents out of 33 interviewed (Residents 6, 17, 24, 27, 43, 53, 54, 58, 72, 77, 112, 113,117, 141 and 163).
- 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 staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas on four of five nursing units (Blue Building Unit 200, 300, [NAME] Building Unit 100 and 200).
November 21, 2023Complaint inspection · 2 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on a review of grievances lodged with the facility and the minutes from Residents' Council meetings and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by five alert and oriented residents out of 16 sampled (Residents 1, 2, 11, 16, and 17).
- 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 a review of clinical records and resident and staff interviews, it was determined that the facility failed to consistently implement a resident's plan of care to assure the use of the necessary level of staff assistance and assistance device to perform safe transfers of one resident out of 20 sampled (Resident 11).
September 28, 2023Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of clinical records, select facility policy, and facility investigative reports, and staff interview, it was determined that the facility failed to ensure that one resident out of the eight sampled residents was free from physical abuse (Resident 2). Findings including: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. [...]
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on a review of clinical records and staff interview it was determined that the facility failed to permit a resident to remain in the facility and not discharge the resident except for defined necessary reasons and failed to ensure the presence of necessary documentation supporting the specific reasons for discharge of one resident out of three residents reviewed (Resident 2)
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on review of clinical records and interview with facility staff it was determined that the facility failed to develop and implement a policy and procedure to ensure that a resident transferred from the facility with the expectation of returning to the facility was permitted to return or met the specific requirements for a facility initiated discharge for one out of three discharged residents reviewed (Resident 2).
September 6, 2023Complaint inspection · 3 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 observation and staff interview, it was determined that the facility failed to store resident care equipment and supplies in a sanitary and orderly manner.
- 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 during a tour of the dietary department equipment storage area and staff interview, it was determined that the facility failed to maintain acceptable food services sanitation practices for the preparation and service of food.
- 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 observation and staff interview it was determined that the facility failed to store drugs and pharmacy supplies in a safe and sanitary manner.
May 12, 2023Standard 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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of minutes from Resident Council meetings and resident and staff interviews, it was determined that the facility failed to demonstrate sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by five (5) of seven (7) residents (Residents 98, 104, 121, 128, 174, 189, and 208).
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, and resident and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards in one resident's room (Resident 70) and failed to timely and adequately address factors contributing to repeated falls for one resident (Resident 182) out of 35 sampled residents.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of clinical records and select facility policy and staff interviews, it was determined that the facility failed to demonstrate timely and consistent monitoring of nutritional paramaters, resident weights, and timely assessment of resident's nutritional status and needs to ensure prompt implementation of measures to prevent continued weight loss for two residents out of four sampled with significant weight loss (Resident 41 and 211)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, a review of clinical records and interviews with staff it was determined that the facility failed to ensure that staff consistently provided a functional communication system to maintain the resident's ability to communicate for two residents out of 35 sampled (Residents 140 and 70).
- 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 review of clinical records and select facility investigations and staff interview, it was determined that the facility failed to thoroughly assess and evaluate a resident's bladder and bowel habits and toileting needs to develop individualized approaches to maintain continence and meet the resident's needs for toileting assistance to the extent possible for one resident (Resident 182) out of 35 sampled residents.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 12 residents sampled (Resident 40).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of five residents (Resident 36)
Fire safety inspections
10 fire safety citations on file: 4 on February 7, 2025, 3 on April 19, 2024, 3 on May 12, 2023.
Every fire safety citation10 citations
- E
Use approved construction type or materials.
K 161 · February 7, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · February 7, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 7, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 7, 2025 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 19, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 19, 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 · April 19, 2024 · Corrected (the home has a date of correction)
- E
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 · May 12, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 12, 2023 · Corrected (the home has a date of correction)
- C
Ensure proper usage of power strips and extension cords.
K 920 · May 12, 2023 · Corrected (the home has a date of correction)