CMS · Pennsylvania Department of Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F580
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F583
F637Assess the resident when there is a significant change in conditionScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F637
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F693
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F695
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F699
F732Post nurse staffing information every day.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F732
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F761
F803Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F812
F814Dispose of garbage and refuse properly.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F814
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F880
F881Implement a program that monitors antibiotic use.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F881
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 395109-20260609-F882
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F600
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F605
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F607
F620Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F620
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F695
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F730
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F756
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F761
F803Ensure 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.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F812
F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F847
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F849
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F880
F908Keep all essential equipment working safely.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F908
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F925
F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F941
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F944
F946Provide training in compliance and ethics.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F946
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-16Record 395109-20250530-F949
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-04-19Record 395109-20240305-F689
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity JHarm
Staffing
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-04-19Record 395109-20240305-F726
F836Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.Scope/severity LHarm
Records
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-04-19Record 395109-20240305-F836
F565Honor the resident's right to organize and participate in resident/family groups in the facility.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F565
F585Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F585
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F609
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F686
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F725
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F730
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F740
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity FStandard
Medication
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F756
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F758
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F761
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F801
F803Ensure 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.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F812
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F838
F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyScope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F868
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F880
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 395109-20240305-F881