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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
7E
1F
Potential for minimal harm
0A
2B
1C
September 11, 2025Standard inspection · 9 citations
- E
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 observations of the meals and dietary services, reviews of the resident council and food committee meeting minutes, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to provide meals at regular time frames and in accordance with resident needs and preferences. (Residents R2, R28, R68, R97, R114 and R116).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on review of clinical records, review of facility policy and interview with staff, it was determined facility did not ensure to develop and care plan related to a resident's diagnosis for one of six residents reviewed (Resident R133)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased upon review of clinical records, interview with staff and review of facility documentation, it was determined that the facility did not ensure a resident receive treatment and care in accordance with professional standards of practice, to a laceration identified after a fall incident for one resident of 24 resident records reviewed (Resident R17).
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased upon review of clinical records and interviews with resident and staff, it was determined the facility failed to ensure that a resident received services to maintain vision for one of 24 resident records reviewed (Resident R83).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two of three residents receiving dialysis reviewed (Residents R1, and R32 ).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wrotePharmacy Services Facility did not ensure to provide medications and/or biologicals, as ordered by the prescriber, to meet the needs of resident ([NAME]) Based on observations, review of resident's clinical record and interview with staff, it was determined that facility failed to ensure timely reordering and availability of mediations from pharmacy for one of four residents reviewed (Resident R24)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations during medication administration, review of clinical records, facility policies and procedures, as well as interview with staff, it was determined that the facility did not ensure the medication error rate was less than five percent.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on clinical record reviews, observations of care and services, interviews with residents and staff and reviews of policies and procedures, it was determined that for one of two residents reviewed for oral health services, the facility failed to provide prompt and routine dental care for each resident. (Resident R9)
- 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 review and staff interview, it was determined that the facility failed to maintain accurate medication administration records for one of 23 residents reviewed. (Resident R24)
October 3, 2024Standard inspection, Complaint inspection · 12 citations
- F
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 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 and discharges for nine of nine months reviewed (January, February, March, April, May, June, July, August, and September).
- 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, observation, and interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that grievance or complaint forms were available to residents or their representatives without asking for two of two units reviewed. (First floor and Second floor)
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, clinical record review, and interviews with staff and residents, it was determined that the facility did not ensure that dietary preferences were honored for three of 23 residents (Residents R72, R97, R65).
- E
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 observation, review of facility documents, and interview with staff and residents, it was determined that the facility did not ensure that meals and snacks were provided at appropriate times for two of two floors observed (First and Second floor).
- D
Give residents a notice of rights, rules, services and charges.
Inspectors wroteBased on review clinical records, review of facility documentation, and interviews with staff, it was determined that the facility failed to inform residents of their rights, rules, regulations, and responsibilities prior to and/or upon the resident's admission for three out of twenty-three residents reviewed. (Residents R29, R74, R317) Findings Include: Resident Council held on October 2, 2024 at 10:00 a.m. with ten awake, alert, and oriented residents revealed that when asked about resident rights being reviewed there were l residents stated they have not received a copy or had a copy reviewed with them. Review of Resident R29's clinical record reveled the resident was admitted on [DATE] and the resident's admission packet was not reviewed with the resident until August 21, 2024. Interview held with Admissions staff, Employee E3 on October 3, 2024 at 12:20 p.m. [...]
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on review of facility documentation, clinical record review, and interviews with staff, it was determined that the facility failed to provide copies of medical records as requested in a timely manner for one of one residents reviewed for medical record request (Resident R317).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility documentation, observation, review of clinical records, and interview with staff, it was determined that the facility failed to ensure feeding assistance was provided for one of twenty-three residents reviewed. (Resident R80) Findings Include: Review of facility documentation titled, Facility Food Service Program states, Policy and Procedure: Red/Yellow Program- the facility has developed a program to identify residents more easily at mealtime who are at nutritional risk and is in need of supervision, partial assist, or extensive feeding assistance during mealtimes. The following outlines the procedure for flagging those residents. 1. The residents on the list will receive a RED sticker or YELLOW sticker on their meal tags in addition to their usual white napkin. Red Program-Extensive Feeding assistance. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, review of facility policy, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure appropriate orders, care plan, and maintenance related to respiratory care were in place for one of twenty-three resident's reviewed. (Resident R83). Findings Include: Review of facility policy titled, CPAP/BiPAP Support with a revision date of March 2015 states, Purpose- 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. Observation on September 30, 2024 at 10:30 a.m. of Resident R83 in their room revealed the resident had a a CPAP machine bedside. [...]
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 23 residents reviewed (Resident R21).
- 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 record and interview with staff, it was determined facility did not ensure that medical records were complete and accurately documented in accordance with accepted professional standards of for two of 23 residents reviewed (Residents R6 and R58)
- B
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observations and interview with staff, it was determined that the facility failed to post contact information for the Pennsylvania Department of Health and the Office of the State Long-Term Care Ombudsman program as required for two of four nursing units that was accessible to residents and their representatives. (First floor and Second Floor) Findings Include: On October 1, 2024 at 11:00 a.m. a facility tour was conducted with the Director of Social Services Employee E7 to observe where the Pennsylvania Department of Health and the Office of the State Long-Term Care Ombudsman program postings were on the first floor and second floor units. Observation during the tour of the first-floor unit revealed there was no information posted as required for the Office of the State Long-Term Care Ombudsman. [...]
- B
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were in a place readily accessible to residents and visitors for two or two nursing units. (First floor and Second Floor) Findings Include: On October 1, 2024 at 11:00 a.m. a facility tour was conducted with the Director of Social Services Employee E7 to observe where the Department of Health Survey binder was located in the facility. Observation of the facilities front lobby revealed the Department of Health survey results binder was behind the desk in the main lobby not accessible for residents or visitors without having to ask. Review of binder revealed the information in the binder also was not up to date. The last results in the binder were from the annual survey dated March 11, 2022. [...]
June 27, 2024Complaint 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 review of clinical records, review of facility policy, review of facility investigation reports, hospital record review, and staff interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) reviewed was free from physical abuse and neglect which resulted in actual harm to Resident R1 who sustained a head injury, hematoma to the right side of the face, lip laceration and required transfer to the hospital. This deficiency was identified as past non-compliance. (Resident R1) Findings Include: A review of the facility policy, titled Lifting Machine, Using a Mechanical, dated July 2017 stated, the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. General Guidelines: at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 1. [...]
February 27, 2024Complaint inspection · 2 citations
- 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 observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for two of two units observed. (Unit One and Unit Two) Findings Include: Review of facility policy titled, Storage of Medication with a revision date of April 2007 states, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrgiators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. During observation of unit one on February 27, 2024 at 10:50 a.m. [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of resident's medical information on two or two nursing units. (Unit one and Unit Two) Findings Include: Review of facility policy titled, Resident Rights last revised December 2016 states, Employees shall treat all residents with kindness, respect, and dignity. The unauthorized release, access, or disclosure of resident information in prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPPA Compliance Officer. During observation of unit one on February 27, 2024 at 10:50 a.m. [...]
December 15, 2023Standard inspection · 11 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to dining for two of two dining rooms observed. (First floor and second floor dining rooms.)
- 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 interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.
- 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 a review of clinical records, facility policies and facility documentation, and interviews with staff, it was determined that the facility failed to review and revise a comprehensive person-centered plan of care in a timely manner, for one of 26 clinical records reviewed (Residents R19).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews with staff and review of the clinical record, it was determined that the facility failed to ensure that that residents received treatment and care in accordance with professional standards of practice related to failing to ensure that recommendations from the resident's cardiologist recommendations were followed for one out of 26 residents reviewed (Resident R24).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interviews, review of facility policy, and review of clinical records, it was determined that the facility failed to follow physician orders for oxygen administration for two of 26 residents observed. (Resident R79 and Resident R42).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a review of facility documents, observations, and interviews with staff, it was determined that the facility did not establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for one resident and failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R86 and Resident R4).
- 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, staff interview, review of facility documents and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication rooms observed (second floor medication room).
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observations, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure therapeutic diets were served per physician orders for three of 26 residents reviewed (Residents R36, R31 and R71).
- D
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 properly.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on a review of the facility's infection control policies and procedures and clinical records and staff interview, it was determined the facility failed to consistently implement an antibiotic stewardship program and maintain a system to effectively monitor antibiotic usage for one of six sampled residents for unnecessary medication usage (Resident R86).
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staffing hours as required for one of four days. Findings Include: On September 15, 2023, at 11:04 a.m. observations at the front receptionist desk revealed staffing data was posted for the previous day, December 13, 2023. Further observation revealed that the staffing indicated the projected number of staff, but the actual number was left blank. Further observations in the lobby area, including the front and back doors of the facility, the first and second- floor nursing units failed to reveal posted staffing data. Interview with the facility receptionist, Employee E10, on December 15, 20253 at approximately 11:06 a.m. confirmed the above-mentioned findings, that there was no staffing data posted anywhere in the lobby area. [...]
Fire safety inspections
8 fire safety citations on file: 3 on September 11, 2025, 4 on October 3, 2024, 1 on December 15, 2023.
Every fire safety citation8 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 3, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 3, 2024 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 3, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 3, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 15, 2023 · Corrected (the home has a date of correction)