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Deficiency Category | Inspection Date: 8/22/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 9/21/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 10/6/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
---|---|---|---|
Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
Quality of Life and Care Deficiencies | |||
Infection Control Deficiencies | |||
Resident Assessment and Care Planning Deficiencies | |||
Nursing and Physician Services Deficiencies | |||
Resident Rights Deficiencies | |||
Nutrition and Dietary Deficiencies | |||
Pharmacy Service Deficiencies | |||
Environmental Deficiencies | |||
Administration Deficiencies |
Date of last standard health inspection: | 8/22/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 10/18/24Read the full report (PDF) 7/29/24Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Pennsylvania: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide enough food/fluids to maintain a resident's health. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide routine and 24-hour emergency dental care for each resident. | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/18/24 | 11/1/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Some |
Assess the resident when there is a significant change in condition | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 7/29/24 | 8/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Assess the resident when there is a significant change in condition | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Some |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | 10/18/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 8/22/24 | 10/2/24 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 9/21/23Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 12/27/23Read the full report (PDF) 7/14/23Read the full report (PDF) 6/13/23Read the full report (PDF) 4/20/23Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Pennsylvania: | |
Average number of Health Deficiencies in the United States: |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 7/14/23 | 7/11/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Assist a resident in gaining access to vision and hearing services. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 4/20/23 | 5/16/23 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | 12/27/23 | 1/11/24 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/13/23 | 6/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
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. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 9/21/23 | 11/1/23 | 1 - Potential for minimal harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 9/21/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 10/6/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 1/30/23Read the full report (PDF) 12/13/22Read the full report (PDF) 7/26/22Read the full report (PDF) 7/22/22Read the full report (PDF) 7/14/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 2/28/23Read the full report (PDF) 1/19/23Read the full report (PDF) |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Pennsylvania: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
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. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 12/13/22 | 1/10/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 7/22/22 | 8/23/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 7/26/22 | 8/23/22 | 2 - Minimal harm or potential for actual harm | Some |
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/30/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 7/26/22 | 8/23/22 | 2 - Minimal harm or potential for actual harm | Some |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Observe each nurse aide's job performance and give regular training. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 1/30/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/14/22 | 7/27/22 | 3 - Actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 10/6/22 | 11/22/22 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide routine and 24-hour emergency dental care for each resident. | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/18/24 | 11/1/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Assess the resident when there is a significant change in condition | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 7/29/24 | 8/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | 10/18/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 4/2/24 | 4/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 7/14/23 | 7/11/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 4/20/23 | 5/16/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 12/27/23 | 1/11/24 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/13/23 | 6/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 12/13/22 | 1/10/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 7/22/22 | 8/23/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 7/26/22 | 8/23/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/30/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 7/26/22 | 8/23/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 1/30/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/14/22 | 7/27/22 | 3 - Actual harm | Few |
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |