Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
91% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 62
Capacity: 68
Deficiencies: 10
Date: Apr 29, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 04/29/2025 to review compliance with licensing regulations and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to quality management plans, staff training, resident equipment safety, food storage and refrigeration, lint removal, medication storage and administration, and support plan documentation. All deficiencies had accepted plans of correction which were implemented by 09/19/2025.
Deficiencies (10)
Quality Management Plan did not include periodic review of complaint procedures, licensing violations, and plans of correction.
Quality Management Plan did not address periodic review of staff person training.
Direct Care Staff Person A did not receive annual training in required topics during training year 2024.
Resident #1 had an enabler bar attached to bed with an uncovered opening posing an entrapment hazard.
Freezer temperatures in kitchen exceeded required limits (15°F and 18°F instead of ≤0°F).
Food items in kitchen pantry were opened and unsealed.
Lint accumulation in lint trap of Dryer #3 was found.
Medications ordered for residents were not available in the home (Lorazepam, Tramadol, Biotene).
Resident #2 was administered incorrect amounts of insulin on multiple dates contrary to sliding scale orders.
Resident #2's support plan did not document how the need for a bedside commode would be met.
Report Facts
License Capacity: 68
Census: 62
Staffing: 82
Waking Staff: 62
Current Hospice Residents: 3
Mobility Need Residents: 20
Freezer Temperature: 15
Freezer Temperature: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in findings related to lack of required annual training | |
| Executive Director | Responsible for updating Quality Management Plan, removing hazardous equipment, conducting audits, and re-educating staff | |
| Director of Health and Wellness | Involved in audits, re-education of staff, and evaluation of resident health | |
| Business Office Manager | Educated on training regulations and responsible for auditing staff training logs | |
| Director of Facilities Operations | Provided training to staff and responsible for auditing compliance | |
| Head Chef | Responsible for discarding unsealed food items and re-education on food storage regulations | |
| Cook | Re-educated on food storage regulations | |
| Director of Facilities Maintenance | Responsible for auditing freezer temperatures | |
| Director of Facilities Operations | Responsible for auditing lint traps of dryers | |
| Health Care Coordinator | Responsible for auditing medication administration and blood sugar monitoring | |
| Med Techs | Re-educated on medication storage and administration |
Inspection Report
Monitoring
Census: 58
Capacity: 68
Deficiencies: 0
Date: May 3, 2024
Visit Reason
The inspection was conducted as a monitoring visit to the facility on 05/03/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 77
Waking Staff: 58
Resident Support Staff: 0
Current Hospice Residents: 9
Residents Served: 58
License Capacity: 68
Residents Age 60 or Older: 58
Residents with Mobility Need: 19
Inspection Report
Renewal
Census: 58
Capacity: 68
Deficiencies: 6
Date: Mar 6, 2024
Visit Reason
The inspection visit was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies related to resident personal equipment, sanitary conditions, surfaces, medication storage, storage procedures, and medication records. Plans of correction were accepted and implemented with ongoing audits and staff re-education to ensure compliance.
Deficiencies (6)
Two unsecured bed enablers attached to resident #1's bed created a potential entrapment hazard.
The common blue Embrace Pro glucometer was used to check multiple residents' blood glucose, violating sanitary conditions.
Two 7 inch long gauges in the wall and a hole in a plexiglass partition with jagged edges in bathroom of bedroom #118 created a potential skin tear hazard.
Resident #5’s medication was not labeled with the date opened.
Resident #5’s glucometer readings did not match the March 2024 Medication Administration Record (MAR).
Resident #6's medication order was discontinued but still indicated as active in the March 2024 MAR.
Report Facts
License Capacity: 68
Residents Served: 58
Current Residents in Hospice: 10
Total Daily Staff: 78
Waking Staff: 59
Inspection Report
Complaint Investigation
Census: 59
Capacity: 68
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 68
Residents Served: 59
Current Hospice Residents: 8
Residents Age 60 or Older: 59
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 22
Inspection Report
Follow-Up
Census: 57
Capacity: 68
Deficiencies: 2
Date: Aug 3, 2023
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility on 08/03/2023.
Findings
The facility was found to have implemented the submitted plan of correction fully. Two deficiencies were identified related to treatment of residents and additional assessments, both of which have been addressed with corrective actions and staff re-education.
Deficiencies (2)
Direct care staff person A spoke harshly to resident #1, threatening to withhold food if the resident continued yelling.
Resident #1’s assessment did not include an assessment for eating or drinking; sections were blank.
Report Facts
Total Daily Staff: 79
Waking Staff: 59
Residents Served: 57
License Capacity: 68
Current Residents in Hospice: 8
Residents 60 Years or Older: 57
Residents with Mobility Need: 22
Inspection Report
Complaint Investigation
Census: 58
Capacity: 68
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Residents Served: 58
License Capacity: 68
Current Hospice Residents: 6
Residents 60 Years or Older: 58
Residents with Mobility Need: 24
Inspection Report
Follow-Up
Census: 56
Capacity: 68
Deficiencies: 1
Date: Feb 28, 2023
Visit Reason
The inspection visit on 02/28/2023 was a partial, unannounced follow-up review triggered by an incident to verify the implementation of the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented with no further violations identified. The facility demonstrated compliance with the regulation requiring residents to be treated with dignity and respect.
Deficiencies (1)
Staff person A slapped the top of resident #1's right hand to stop the resident from moving the hand during an episode of fecal incontinence.
Report Facts
License Capacity: 68
Residents Served: 56
Current Residents in Hospice: 4
Total Daily Staff: 80
Waking Staff: 60
Residents with Mobility Need: 24
Residents Age 60 or Older: 56
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 8, 2022
Visit Reason
Licensing inspections were conducted on 11/08/2022 and 11/09/2022 for the purpose of facility licensing oversight.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Census: 45
Capacity: 68
Deficiencies: 4
Date: Nov 2, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified deficiencies related to locking poisonous materials, maintaining sanitary conditions, outdated food, and resident record content. The facility submitted a plan of correction which was accepted and fully implemented.
Deficiencies (4)
Poisonous materials were found unlocked and accessible to residents.
Sanitary conditions were not maintained; food debris and liquids were found in kitchen equipment and rusted tweezers in first aid kit.
Outdated food (frozen Grouper Burger dated 7/3/21 & 7/4/21) was found in the freezer.
Resident #3's photograph in the record was outdated.
Report Facts
License Capacity: 68
Residents Served: 45
Staffing: 59
Waking Staff: 44
Hospice Residents: 2
Residents with Mobility Need: 14
Inspection Report
Complaint Investigation
Census: 47
Capacity: 68
Deficiencies: 0
Date: May 21, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/21/2021.
Complaint Details
The inspection was complaint-driven, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 64
Waking Staff: 48
Residents Served: 47
License Capacity: 68
Current Hospice Residents: 4
Residents with Mobility Need: 17
Residents Age 60 or Older: 47
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