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 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
3K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
13E
0F
Potential for minimal harm
0A
0B
0C
July 10, 2026Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of the Pennsylvania Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to follow physician's orders to hold blood thinner and anticoagulant medications prior to a scheduled surgical procedure resulting in delayed surgery for one of seven residents reviewed (Resident 7).
January 8, 2026Standard inspection · 11 citations
- 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 residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 36 residents reviewed (Resident 23).
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
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 a long-term intravenous catheter and a midline catheter (a type of peripheral catheter inserted into a large vein in the upper arm used to deliver fluids and/or medications) were flushed prior to and/or after medication administration for two of 36 residents reviewed (Residents 4, 10).
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure communication between a dialysis provider and the facility's nursing staff for one of 36 residents reviewed (Resident 6).
- 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 stored under sanitary conditions.
- 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 a comprehensive significant change Minimum Data Set assessment was completed in the required time frame for one of 36 residents reviewed (Resident 1), and failed to complete a significant change Minimum Data Set assessments for one of 36 residents reviewed (Residents 91).
- D
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 three of 36 residents reviewed (Residents 6, 34, 86).
- 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 facility policies, 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 36 residents reviewed (Resident 40).
- 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 two of 36 residents reviewed (Residents 2, 5).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of 36 residents reviewed (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 review of clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for one of 36 residents reviewed (Resident 3).
- 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 correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
January 9, 2025Standard inspection · 20 citations
- E
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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for five of 31 residents reviewed (Residents 46, 54, 65, 73, 77).
- 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 provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for three of 31 residents reviewed (Residents 27, 50, 77), and failed to ensure that bowel protocols were followed as ordered by the physician for one of 31 residents reviewed (Resident 69).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on resident and staff interviews, and a meal test tray, it was determined that the facility failed to serve food items that were palatable to the residents.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain dignity for one of 33 residents reviewed (Resident 34) who had an indwelling urinary catheter.
- 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for two of 31 residents reviewed (Residents 10, 46).
- 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 staff interviews, it was determined that the facility failed to provide a homelike environment for three of 31 residents reviewed (Residents 19, 69, 84).
- 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 ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital for two of 31 residents reviewed (Residents 61, 73).
- D
Ensure each resident receives an accurate assessment.
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 complete accurate Minimum Data Set assessments for two of 31 residents reviewed (Residents 61, 74).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified when needed for two of 31 residents reviewed (Residents 29, 73).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments and preventative measures for pressure ulcers were provided as ordered by the physician for two of 31 residents reviewed (Residents 19, 50).
- 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 a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that restorative nursing programs to maintain or improve physical abilities were provided as ordered and/or care planned for one of 31 residents reviewed (Resident 10).
- 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, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of 31 residents reviewed (Resident 34).
- 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 residents received oxygen as ordered by the physician for one of 31 residents reviewed (Resident 29).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 31 residents reviewed (Resident 50).
- D
Ensure medication error rates are not 5 percent or greater.
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 maintain a medication administration error rate of less than five percent.
- 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 facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in one of three medication carts reviewed (First floor cart), failed to discard expired medical supplies, and failed to sign out routine narcotics on the appropriate narcotic medication card (Residents 37, 69).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide adaptive eating equipment as ordered by the physician for one of 31 residents reviewed (Resident 69).
- 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 correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- 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 31 residents reviewed (Resident 50).
February 29, 2024Standard inspection · 11 citations
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 37 residents reviewed (Resident 7).
- 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 manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store unopened (unused) multi-dose containers of insulin according to manufacturer's instructions for one of 37 residents reviewed (Resident 22), and failed to ensure that controlled refrigerated medications were stored in a separately-locked, permanently-affixed container in one of two medication refrigerators reviewed (third-floor east medication room refrigerator).
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that dietary staff wore appropriate hair coverings, and failing to ensure that a microwave was clean and free of deterioration, for one of three microwaves reviewed (first-floor pantry)
- D
Ensure each resident receives an accurate assessment.
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 complete accurate comprehensive Minimum Data Set assessments for two of 45 residents reviewed (Residents 30, 72).
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that baseline care plans included the information and instructions needed to provide person-centered care for one of 37 residents reviewed (Resident 80).
- 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 reviews and staff interviews, it was determined that the facility failed to ensure that residents' care plans were reviewed and revised to reflect their current care needs for two of 37 residents reviewed (Residents 35, 42).
- D
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 complete treatments as ordered by the physician for one of 37 residents reviewed (Resident 78).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 37 residents reviewed (Residents 42).
- 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 37 residents reviewed (Resident 53).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical records reviews, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 37 residents reviewed (Residents 7, 42).
- 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 correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
November 8, 2023Complaint inspection · 3 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of four residents reviewed (Residents 1, 2), resulting in Immediate Jeopardy to the resident's physical/mental health and safety. This deficiency was cited as past non-compliance.
- K
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for one of five nurse aides reviewed upon hire (Nurse Aide 2) and staff failed to report physical abuse of one resident (Resident 1) in a timely manner which allowed a second resident to be physically abused (Resident 2) putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical safety.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to honor a power of attorney's right to make informed choices and participate in treatment decisions for one of four residents reviewed (Resident 1).
October 20, 2023Complaint inspection · 3 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of facility policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that supervision and adequate interventions were in place to prevent a resident from receiving food items from other residents outside of their ordered diet restrictions for one of six residents reviewed (Resident 2), and failed to ensure that supervision and adequate interventions were in place to prevent a resident from giving other residents food items outside of their ordered diet restrictions for one of six residents reviewed (Resident 1). The facility's failure created a situation in which Resident 2 obtained a food item outside of his ordered diet restriction causing him to accidentally choke to death. [...]
- 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included specific and individualized interventions for two of six residents reviewed (Residents 1, 2).
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of accident hazards, and for ensuring that each resident receives and is provided food prepared in a form designed to meet individual needs.
Fire safety inspections
20 fire safety citations on file: 4 on January 8, 2026, 5 on January 9, 2025, 11 on February 29, 2024.
Every fire safety citation20 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2026 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 8, 2026 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · January 9, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 9, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 9, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 9, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · January 9, 2025 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 29, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 29, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 29, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 29, 2024 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · February 29, 2024 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 29, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 29, 2024 · Corrected (the home has a date of correction)