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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
22D
5E
0F
Potential for minimal harm
0A
0B
0C
May 7, 2026Standard inspection · 3 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, facility policies, facility documents, observations, and staff interviews, it was determined that the facility failed to ensure the safety and adequate supervision and ensure that safety devices were in place for five of six residents reviewed for risk of wandering and elopement. (Residents 122, R21, and R39).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review and record review, the facility failed to implement an effective and comprehensive water management program necessary to identify, monitor, control, and reduce hazardous conditions supporting the growth and spread of Legionella within the facility water system and failed to ensure proper infection control practices during the administration of eye drops for one of one resident observed. (Resident R101)Findings inlcude: Review of the CDC (Center for Disease Control and Prevention- a major public health agency in the United States that works to: [...]
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on review of facility documentation, clinical records and staff interviews, it was determined that the facility failed to ensure an appropriate, safe, and properly documented discharge process for 1 of 2 residents reviewed for discharge practices (Resident R 118).
January 8, 2026Complaint inspection · 1 citation
- D
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 review, interviews with residents and staff, reviews of policies and procedures, nursing staffing assignments, pertinent human resource documents and the report form for investigation of alleged abuse, neglect, misappropriation of property (PB-22), it was determined that the facility failed to ensure that each resident was free from physical and mental abuse. (Resident R1)
May 23, 2025Standard inspection · 12 citations
- 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 facility policies, observation, interviews with residents and staff, it was determined the facility failed to promote care for residents that maintains or enhances dignity and respect related to privacy during treatment administration and ensuring residents' care and comfort is maintained by providing necessary necessities of bedding for two of eight residents reviewed. (Resident 4 and Resident 370)
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility documentation, review of clinical records, 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 to the hospital for one of two hospitalizations reviewed (Resident R117). Findings Include: Review of Resident R117's clinical record revealed a nursing progress note dated March 18, 2025, that indicated the resident was transferred to the local hospital for evaluation. Review of documentation provided by the Nursing Home Administrator on May 23, 2025, at 10:35 a.m. revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident R117's facility-initiated emergency transfers to the hospital as required until May 21, 2025. Interview on May 23, 2025, at 10:54 a.m. [...]
- 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 policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of two new admissions reviewed (Resident R319). Findings Include: Review of facility policy, Care Plan-Baseline dated 2001 revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admissions. Review of Resident 319's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia (progressive degenerative disease of the brain). A comprehensive care plan which was initiated on May 12, 2025 did not indicate a baseline care plan for dementia. On May 21, 2025, at 1:48 p.m. an interview with the Director of Nursing, Employee E2 confirmed that Resident R319 did not have a baseline care plan. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for 3 of the six residents reviewed (Residents R319, R62 and R45).
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined the facility failed to ensure that medically related social services were provided as required for four of eight residents reviewed related to routine care plan meetings. (Residents R60, R61, R68, R97) Finds include: Review of facility policy titled Care Plans - Baseline dated March 2022 revealed the baseline plan includes instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care and must include minimum healthcare information necessary to properly care for the resident including but not limited to initial goals, physician orders, dietary orders, therapy services, social services, PASARR recommendations. [...]
- 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, staff interview, and pharmacy review recommendations, it was determined that the facility failed to act on the pharmacy recommendations in a timely manner for one of three residents reviewed (Resident R78).
- 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 observations, review of facility policies and interview with staff, it was determined that the facility failed to ensure that medications carts were kept locked and refrigerated medications kept dry and at proper temperatures on one of two nursing floors. (2nd Floor)
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations of the operations of the food and nutrition services department, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to ensure each resident received and the facility provided foods and drinks that were palatable, attractive and at a safe and appetizing temperature. Residents (R14,R3, R86, R115, R55, R85, R94, R94, R79).
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for three of 21 residents. (R80, R15). Findings Include: Review of Facility Policy: Foods Brought by Family/Visitors undated, states Food brought to the community by visitors and family is permitted. Community staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Safe food handling practices will be explained to family/visitors in a language and format they understand. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Contains will be labeled with the resident's name, the items and the use by date. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, facility documentation, and staff interviews, it was determined the facility failed to implement appropriate tracking and surveillance of infection for two of 3 months reviewed April 2025 and May 2025. (Resident R97)
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations of the physical environment of the food and nutrition services department and interviews with staff, it was determined that essential equipment used to operate the main kitchen where foods and beverages were prepared for the residents was not in safe functional condition.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on environmental observations of the food and nutrition services department, reviews of the consulting pest control operator's reports and interviews with staff, it was determined that the facility failed to maintain an effective pest control program for the building.
May 8, 2025Complaint inspection · 3 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 facility policies, clinical records, and interviews with staff, it was determined that the facility failed to ensure that grievance regarding abuse/neglect was filed, tracked and promptly resolved for one of six residents reviewed. (Resident R1). Findings Include: Review of facility policy titled, Grievances/Complaints, Filing dated April 2017 states, 8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. 9. The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one of six residents reviewed. (Resident R1) Findings Include: Review of facility policy titled, Abuse Prevention Program revised December 2016 states, Policy Statement-Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of facility records revealed Resident R1 was admitted to the facility on [DATE]. The resident had the following diagnoses: [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to provide evidence that an allegation of abuse/neglect was thoroughly investigated for one of six residents reviewed. (Resident R1). Findings Include: Review of facility policy titled, Abuse Prevention Program revised December 2016 states, Policy Statement-Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of facility grievance form titled, Resident/Family Concerns dated April 21, 2025 states, Concern-Nursing Received complaint by section is not checked off. [...]
November 4, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical record, review of facility documentation and interview with staff, it was determined that the facility failed to ensure that one of six residents reviewed receive the required assistance via mechanical lift during a bed to chair transfer. This failure resulted in actual harm to Resident R1 whose left leg got twisted during transfer and sustained a fracture of the left femur (thigh bone). (Resident R1)
August 9, 2024Standard inspection, Complaint inspection · 7 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on environmental observations of the food and nutrition department, interviews with staff and reviews of policies and procedures, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety.
- 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 environmental observations of two of thirty-six resident rooms, reviews of policies and procedures, interviews with staff and residents, it was determined that the facility failed to ensure reasonable care for the protection of resident's property from loss or theft for two of 22 residents reviewed. (Resident R88 and Resident R27)
- 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 observation, clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan related to edema for one of 22 resident records reviewed (Resident R42).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and interviews with staff, it was determined that the facility failed to ensure a neurological assessments were completed and to obtain orders for the use of a hand splint for two of 22 residents records reviewed (Resident R85 and Resident R42).
- 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, review of facility documentation and interviews with staff, it was determined that the facility did not ensure that each resident received adequate supervision to prevent a resident from falling out of the bed during personal care for one of 22 records reviewed (Resident R38).
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on review of clinical records, interviews with resident and staff, and facility policy. it was determined that the facility failed to obtain services in a timely manner when the facility could not obtain these services on site to meet the needs of one of 22 resident records reviewed (Resident R62).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain proper infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of 22 residents reviewed (Resident R8 and R42 )
April 9, 2024Complaint inspection · 1 citation
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, interviews with staff and review of policies and procedures, it was determined that the facility failed to ensure that medications were administered according to professional standards of practice before and during dialysis treatment for one of two residents on hemodialysis.(Resident R1)
Fire safety inspections
27 fire safety citations on file: 6 on May 7, 2026, 19 on May 23, 2025, 2 on August 9, 2024.
Every fire safety citation27 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 7, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 7, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 7, 2026 · 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 · May 7, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 7, 2026 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 7, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 23, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 23, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 23, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 23, 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 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 23, 2025 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · May 23, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · May 23, 2025 · Corrected (the home has a date of correction)
- B
Conduct risk assessment and an All-Hazards approach.
E 6 · May 23, 2025 · Corrected (the home has a date of correction)
- B
Address patient/client population and determine types of services needed.
E 7 · May 23, 2025 · Corrected (the home has a date of correction)
- B
Create arrangements with other facilities to receive patients.
E 25 · May 23, 2025 · Corrected (the home has a date of correction)
- B
Provide primary/alternate means for communication.
E 32 · May 23, 2025 · Corrected (the home has a date of correction)
- B
Provide a means of sharing information on occupancy/needs.
E 34 · May 23, 2025 · Corrected (the home has a date of correction)
- B
Establish emergency prep training and testing.
E 36 · May 23, 2025 · Corrected (the home has a date of correction)
- B
Establish staff and initial training requirements.
E 37 · May 23, 2025 · 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 · August 9, 2024 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 9, 2024 · Corrected (the home has a date of correction)