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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
5E
1F
Potential for minimal harm
0A
1B
0C
September 5, 2025Standard inspection, Complaint inspection · 5 citations
- E
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, resident interviews, and staff interviews it was determined that the facility failed to ensure required posting for the Department of Health were displayed at the facility. Findings Include: Observation on September 2, 2025 at 10:05 a.m. revealed the main lobby, A wing, B wing, and C wing did not have any postings or signage for the Department of Health. This was confirmed by the front desk receptionist Employee E7 at 10:09 a.m. An interview was held with the Nursing Home Administrator, Employee E1 at 10:10 a.m. The interview revealed that there was one spot outside of the lobby area where the name and phone number are posted and stated, it must have been taken down by one of the residents. Employee E1 confirmed that this is the only place where the Department of Health reporting phone number is posted in the facility. [...]
- 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 safe and home-like environment for one of three nursing units observed. (C wing)Findings Include: On September 2, 2025, at 12:02 p.m., observation conducted on C wing of the bathroom of Resident R80's room, revealed that the covering of the heater/cooler- outlet- was not properly fixated to the heater/cooler- outlet and the rusted metal pieces were exposed around the base of the wall. The same observation was noted on September 3, 2025, at 10:01 a.m., on September 4, 2025, at 10:31 a.m., and on September 5, 2025, at 9:31 a.m. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure residents received quality care related to incontinence care for and medication administration for three of twenty-one residents reviewed (R5, R57, R114)
- E
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 staff hours as required. Findings Include:On September 5, 2025 at 10:34 a.m. observations at the front lobby area revealed staffing was posted is a spot behind the front desk receptionist on the wall in a clear sleeve. Observation of the posting revealed the posting would be difficult to access for people with mobility issues due to the height of the posting and the position behind the receptionist desk. Employee E7 the front desk receptionist, was asked if this was the only placed that the staffing was posted and Employee E7 replied, I believe so. The form in the clear sleeve on the wall was from September 4, 2025 and the form was left blank without any of the staffing information filled in. [...]
- 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 observations, clinical record review, review of facility policy and interviews with staff, it was determined that the facility did not ensure a care plan was developed for one of twenty-two residents reviewed. (Resident R57)Findings Include: Review of facility policy titled, Comprehensive Care Planning Policy with a revision date of March 20, 2025 states, Policy- An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. Further review of the policy revealed, Procedure- the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. [...]
April 8, 2025Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, and interview with staff, it was determined that the facility failed to ensure that a rational was provided for the discontinuation of blood sugar monitoring for 6 of 6 residents reviewed who were insulin dependent (Resident R1, R2, R3, R4, R5, R6).
November 12, 2024Standard inspection, Complaint inspection · 7 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on staff and family interviews and the review of clinical records, it was determined that the facility failed to ensure that residents had the right to participate in the development and implementation of a person-centered plan of care for 2 out of 20 residents reviewed (Resident R61 and R71).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations of care and services, reviews of clinical records and interviews with residents and staff, it was determined that the facility failed to provide care preferences and reasonable accommodations for the adaptive equipment used to enhance mobility and bathing for one of three residents reviewed. (Resident R10)
- 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 staff interview and the review of the clinical record, it was determined that the facility failed to ensure that a person-center plan of care was developed for a resident with a history of deep vein thrombosis (blood clots) and anticoagulant medications for 1 out of 20 residents reviewed (Resident R61).
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to develop and implement an effective discharge planning process for 1 out of 20 residents reviewed (Resident R61).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to notify the physician regarding a change in Resident R61's meal and fluid consumption for 1 out of 20 residents reviewed (Resident R61).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of clinical records, observations, interviews with staff and residents, it was determined that the facility failed to ensure the availability of necessary emergency tool kit for one resident, out of the six residents receiving hemodialysis (R36).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders, for one of seven residents' medication administration observed, resulting in a significant medication error (Resident R21).
October 2, 2024Complaint inspection · 1 citation
- B
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 review of facility documentation 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 as required.
February 2, 2024Standard inspection, Complaint inspection · 15 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on the review of clinical records, facility investigation, and interviews with residents and staff, it was determined that the facility failed to treat residents with respect and dignity for three of 20 residents reviewed. (Resident R242, R37, R39) Findings Include: Review of facility investigation dated October 16, 2023, revealed that Resident R242 reported that his nurse aide said she wished the facility would stop taking heavy ass people to save her back while turning him for care on October 15, 2023. Review of statement from Employee E13, nurse aide, who provided care to Resident R242, confirmed that she stated to her co-worker that she wishes that the facility would stop taking heavy ass people to save her back while repositioning Resident R242 to provide care. Interview with the facility administrator and director of nursing on January 29, 2024, at approximately 2:00 p.m. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of facility policy, observations, resident and staff interview, it was determined that the facility failed to answer call bells in a timely manner for four of 20 residents (Residents R34, R57, R82, R25), failed to accommodate the residents' needs related to having access wheelchair accessible bathroom including sink and toilet for one of the two residents reviewed (Resident R72) and the use of bed rails for 2 out of 20 residents observed.(Resident R25 and Resident R18)
- 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 clinical record reviews and resident and staff interviews, it was determined that the facility failed to support and accommodate a resident's choices and preferences for one of two residents reviewed (Resident R72).
- 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 residents' medical information and phone communication on two of six nursing units (A unit).
- 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 facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to ensure that one resident remained free from abuse of 20 residents reviewed. (Resident R3)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to discharge for one of four closed records reviewed (Resident R302).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act, facility policies, interviews and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments and medication were performed in accordance with professional practices for one of one residents reviewed (Resident 295).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on closed record review, review of facility documents and interview with staff, it was determined that the facility failed to ensure that a physician's orders was followed related a psychotropic medication one of four closed records reviewed. (Resident R302)
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of facility policy, review of clinical record, observations, and interviews with staff and residents, it was determined that the facility failed to administer a resident's tube flushes per physician orders for one of one resident reviewed receiving enteral nutrition. (Resident R79).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to provide mental health services to a resident with a mental disorder for one of 20 residents reviewed (Resident R302). Review of the closed record revealed that Resident 302 was admitted to the facility on [DATE], and discharged on December 20, 2023, with a bipolar disorder current episode manic severe with psychotic features (is a mental health condition characterized by episodes of mania (or hypomania) and depression. When someone experiences a manic episode with psychotic features, it means they are in a state of elevated mood, energy, and sometimes psychosis). Hospital record indicated Resident R302 had a prescription of Quetiapine 25 mg tablet commonly known as Seroquel take 1.5 tablets (37.5 mg total by nouth 3 times a day. Last time given December 18, 2023, to treat agitation. [...]
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, clinical record review and resident and staff interview, it was determined that the the faciltiy failed to provide a diet in accordance with resident's preference for one of 20 residents reviewed. (Resident R43)
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on review of facility documents and review of clinical record and staff and resident interviews, it was determined that the facility failed to ensure a resident and resident's representative had the capacity to understand the terms of a binding arbitration agreement for 4 of 5 residents reviewed (Residents R72, R86, R29, R59).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review facility policy and review of facility documents and interview with staff, it was determined that the facility did not maintain an effective infection prevention program related to hand hygiene during wound care observation and medication administration for five of eight residents observed. (Residents R295, R4, R84, R48, R65 and R8)
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on the review of facility records, observations and interviews with resident and staff, it was determined that the facility failed to ensure a sanitary environment on one three of three nursing units observed. (C unit) Finding Include: On January 29, 2024, at approximately 10:07 a.m. a significant urinal odor was detected on the C unit near room C43. On February 1, 2024, at 9:23 a.m. an observation was taken place with Housekeeping Director, Employee E15 who reported room B27 has a significant unsanitary odor. The root cause Employee E15 reported that Resident R39 and Resident R37 refuse care. Both residents agreed to take showers as it was their shower days and investigate where the significant odor was coming and prevent future reoccurrences. On February 1, 2024, at 10:03 a.m. [...]
October 27, 2023Complaint inspection · 1 citation
- 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 facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor meal and nutritional supplement consumption for one of six residents reviewed. (Resident CL1)
Fire safety inspections
14 fire safety citations on file: 6 on November 12, 2024, 8 on February 2, 2024.
Every fire safety citation14 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 12, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 12, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 12, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 12, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 12, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · February 2, 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 · February 2, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 2, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 2, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 2, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 2, 2024 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 2, 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 2, 2024 · Corrected (the home has a date of correction)