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 60 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
42D
15E
1F
Potential for minimal harm
0A
0B
0C
June 16, 2026Complaint inspection · 2 citations
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.
- 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 store and prepare food under sanitary conditions. The facility's policy for food preparation, dated January 20, 2026, revealed that all utensils, food contact equipment, and food contact surfaces would be cleaned and sanitized after every use. The facility's policy for staff attire, dated January 20, 2026, revealed that all staff members would have facial hair properly restrained. Observations in the main kitchen on June 16, 2026, at 10:26 a.m. revealed the large bin of flour had the plastic scoop stored in the container, and the sugar bin had a plastic bowel stored in the container. Observations of the main kitchen floor revealed sugar packets, removable dried food debris, and other nonfood removable debris (a piece of black plastic). [...]
January 23, 2026Standard inspection, Complaint inspection · 13 citations
- E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 non pharmalogical interventions were attempted prior to the administration of a psychotropic medication for one of 37 residents reviewed (Resident 29).
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on review of Food Committee minutes, as well as observations and resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the main kitchen.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on review of planned, written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu, and failed to inform residents of menu changes.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on review of policies and Resident Council/Food Committee meeting minutes, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was 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 review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen was labeled, dated and secured.
- 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 record reviews, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for one of 37 residents reviewed (Residents 20).
- 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 clean and homelike environment for three of 37 residents reviewed (Residents 15, 86, 88,).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on a review of facility policy, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with dental care as scheduled for one of 13 residents reviewed (Resident 1).
- 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 policies and clinical records, observations and staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for two of 37 residents reviewed (Resident 17, 57) who were at risk for falls.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medications properly for one of 37 residents reviewed (Resident 47).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on a review of facility policy, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents were provided with assistive devices for eating as ordered by the physician for one of 13 residents reviewed (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 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the proper hand-washing procedures were followed, and that proper infection control practices were followed for two of 37 residents reviewed (Residents 47, 80).
May 29, 2025Complaint inspection · 2 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 clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that residents were free from neglect which resulted in harm as evidenced by a fall with fracture for one of five residents reviewed (Resident 3).
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that a safe environment was provided for one of five residents reviewed (Resident 3) resulting in a fall with fracture.
January 15, 2025Standard inspection, Complaint inspection · 15 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, as well as resident and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures.
- 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 facility policy and Food Committee meeting minutes, and resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve resident grievances regarding cold food.
- E
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 ensure that physician's orders were followed for two of 30 residents reviewed (Residents 40, 53).
- 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 facility policy, as well as observations and staff interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety by failing to store and serve food 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 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.
- 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 clean and homelike environment in resident rooms for two of 30 residents reviewed (Residents 5, 29).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on a review of policies, clinical records, personnel files, and investigative reports, as well as interviews with staff, it was determined that the facility failed to ensure that the abuse policy was followed for one of 30 residents reviewed (Resident 28), and failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hire for one of four employees reviewed (Registered Nurse 1).
- 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 policy and clinical record reviews, and staff interviews, it was determined that the facility failed to notify the resident, responsible party, and Ombudsman, in writing, regarding the reason for hospitalization for two of 30 residents reviewed (Residents 68, 70).
- 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate parties were notified about the facility's bed-hold policy upon transfer to the hospital for two of 30 residents reviewed (Residents 68, 70).
- 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 facility 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 one of 30 residents reviewed (Resident 29).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for seven of 30 residents reviewed (Residents 3, 14, 20, 24, 36, 63, 66).
- 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, as well as staff interviews, it was determined that the facility failed to ensure that a resident's transfer status was followed for one of 30 residents reviewed (Resident 68).
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that there was sufficient nursing staff available to transport residents to activities and to provide licensed nursing staff in the facility's main dining area for the lunch and dinner meals.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of 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 hire dates for one of three nurse aides reviewed (Nurse Aide 10).
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents' drink and food preferences were honored.
October 22, 2024Complaint inspection · 1 citation
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with occupational therapy recommendations for one of four residents reviewed (Resident 3).
September 9, 2024Complaint inspection · 1 citation
- 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 pressure ulcers were assessed and documented on for two of four residents reviewed (Residents 1, 3).
July 17, 2024Complaint inspection · 1 citation
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of the facility's job descriptions and interviews with staff, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility.
May 16, 2024Complaint inspection · 1 citation
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of the facility's job descriptions, and interviews with staff, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility.
February 23, 2024Standard inspection · 18 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 clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding dietary complaints.
- E
Provide enough food/fluids to maintain a resident's health.
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 weights were obtained and documented as ordered for residents with weight loss for two of 51 residents reviewed (Residents 12, 42) and failed to ensure supplements were provided and documented as ordered for two of 51 residents reviewed (Residents 77, 97).
- E
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 ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 51 residents reviewed (Residents 15, 29).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on individual resident interviews and an interview with a group of residents, as well as a meal test tray, it was determined that the facility failed to serve food items that were palatable to residents.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 25 residents reviewed (Resident 31).
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's attending physician was notified about changes in weight for one of 51 residents reviewed (Resident 19), failed to notify the physician regarding an elevated blood sugar and change in skin condition for one of 51 residents reviewed (Resident 47), and failed to notify the physician of purulent drainage from a resident's nephrostomy tube for one of 51 residents reviewed (Resident 97) .
- 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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for three of 51 residents reviewed (Residents 7, 42, 68).
- 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 facility policy 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 care needs for one of 51 residents reviewed (Resident 29).
- 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 ensure that physician's orders were followed for one of 51 residents reviewed (Resident 33) and failed to prevent a delay in care for one of 51 residents reviewed (Resident 97) resulting in his hospitalization.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 treatments for pressure ulcers were provided as ordered by the physician for one of 51 residents reviewed (Resident 42).
- 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 a review of clinical records, as well as staff interviews, it was determined that the facility failed to provide suprapubic urinary catheter changes as ordered by the physician for one of 51 residents reviewed (Resident 35).
- 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 51 residents reviewed (Resident 95).
- D
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteBased on review of personnel files, as well as staff interviews, it was determined that the facility failed to verify registry verification prior to allowing individuals to work as a nurse aide for one of five newly hired nurse aides reviewed (Nurse Aide 4).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of 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 hire dates for four of five nurse aides reviewed (Nurse Aides 5, 6, 7, 8).
- 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician or designee responded timely to a pharmacy recommendation for one of 51 residents reviewed (Resident 15).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to offer routine dental services for one of 51 residents reviewed (Resident 91).
- 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing care for two of 51 residents reviewed (Residents 12, 109).
December 28, 2023Complaint inspection · 2 citations
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on review of policies and clinical records, as well as 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 1).
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on facility policy and observations, as well as family, resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures.
November 15, 2023Complaint inspection · 2 citations
- 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 staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of three residents reviewed (Resident 2).
- D
Provide and implement an infection prevention and control program.
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 staff followed proper infection control practices during wound care for one of three residents reviewed (Resident 2).
September 13, 2023Complaint inspection · 2 citations
- 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 review and revise residents' care plans for one of nine residents reviewed (Resident 3).
- 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, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by failing to follow physician's orders and care-planned interventions for one of nine residents reviewed (Resident 2), who was at risk for falls.
Fire safety inspections
8 fire safety citations on file: 1 on January 23, 2026, 2 on January 15, 2025, 5 on February 23, 2024.
Every fire safety citation8 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2025 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · January 15, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 23, 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 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 23, 2024 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · February 23, 2024 · Corrected (the home has a date of correction)