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Deficiency Category | Inspection Date: 10/18/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 11/16/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 12/22/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
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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: | 10/18/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | |
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 appropriate treatment and care according to orders, resident’s preferences and goals. | 10/18/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Few |
No Infection Control 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 each resident receives an accurate assessment. | 10/18/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/18/24 | 11/15/24 | 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. | 10/18/24 | 11/15/24 | 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) |
---|---|---|---|---|
Observe each nurse aide's job performance and give regular training. | 10/18/24 | 11/15/24 | 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) |
---|---|---|---|---|
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. | 10/18/24 | 11/15/24 | 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. | 10/18/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Many |
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. | 8/7/24 | 8/7/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/18/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental 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) |
---|---|---|---|---|
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 10/18/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | 10/18/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Some |
Date of last standard health inspection: | 11/16/23Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | No complaint inspections |
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: |
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) |
---|---|---|---|---|
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. | 11/16/23 | 12/15/23 | 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) |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | 11/16/23 | 12/15/23 | 2 - Minimal harm or potential for actual harm | Few |
No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
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 dignified existence, self-determination, communication, and to exercise his or her rights. | 11/16/23 | 12/15/23 | 1 - Potential for minimal harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 11/16/23 | 12/15/23 | 1 - Potential for minimal harm | Many |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
No Pharmacy Service Deficiencies were found during this inspection period. |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 12/22/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 3/24/23Read the full report (PDF) 12/22/22Read the full report (PDF) 11/14/22Read the full report (PDF) 10/7/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 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) |
---|---|---|---|---|
Ensure the activities program is directed by a qualified professional. | 10/7/22 | 11/3/22 | 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. | 11/14/22 | 12/9/22 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Some |
No Infection Control 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) |
---|---|---|---|---|
Assure that each resident’s assessment is updated at least once every 3 months. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Some |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 12/22/22 | 1/9/23 | 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) |
---|---|---|---|---|
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 3/24/23 | 4/7/23 | 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) |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 12/22/22 | 1/9/23 | 1 - Potential for minimal harm | Many |
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. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Few |
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. | 12/22/22 | 1/9/23 | 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) |
---|---|---|---|---|
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Many |
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. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Many |
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. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Many |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Many |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 12/22/22 | 1/9/23 | 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 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. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental 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) |
---|---|---|---|---|
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | 12/22/22 | 1/9/23 | 1 - Potential for minimal harm | Many |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Many |
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. | 8/7/24 | 8/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure the activities program is directed by a qualified professional. | 10/7/22 | 11/3/22 | 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. | 11/14/22 | 12/9/22 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Some |
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 3/24/23 | 4/7/23 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Few |
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. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 12/22/22 | 1/9/23 | 2 - Minimal harm or potential for actual harm | Many |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 10/7/22 | 11/3/22 | 2 - Minimal harm or potential for actual harm | Many |
This nursing home has not had any infection control inspections in the past 3 years. |