The Vardell Report.Burgh Care Center

Across 16 inspections from November 2023 to August 2026, state surveyors documented 128 findings at Burgh Care Center; 122 have a recorded correction and 6 await one; CMS lists 5 enforcement actions in the window.

Inspections

16

2023–2026, complaint and standard

Findings

128

Deficiencies cited by state inspectors

Corrected

122

Of 128 findings, with a recorded correction date

Penalties

5

4 fines; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 242026

   Complaint investigation

   6 findings

   • F584Honor 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.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jul 92026

   Complaint investigation

   4 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jul 31, 2026
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level DNo actual harm, potential for moreCorrected Jul 31, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 31, 2026
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level DNo actual harm, potential for moreCorrected Aug 5, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Apr 102026

   Standard health inspection

   35 findings

   The same visit included a complaint investigation.

   • 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.Level FNo actual harm, potential for moreCorrected May 26, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 26, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • 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.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F946Provide training in compliance and ethics.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level ENo actual harm, potential for moreCorrected May 26, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • 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.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • 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.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected May 26, 2026
   • F575Post 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.Level CPotential for minimal harmCorrected May 26, 2026
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected May 26, 2026
   • F579Provide information about how to apply for and use Medicare and Medicaid benefits.Level CPotential for minimal harmCorrected May 26, 2026

   Enforcement Action

   Civil money penalty, $27,378 imposed April 15, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 10, 2026, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jan 292026

   Complaint investigation

   1 finding

   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Feb 25, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Dec 42025

   Complaint investigation

   3 findings

   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
   • F844Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.Level DNo actual harm, potential for moreCorrected Dec 12, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. May 222025

   Complaint investigation

   1 finding

   • F917Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.Level DNo actual harm, potential for moreCorrected Jun 3, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Apr 282025

   Complaint investigation

   1 finding

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level GActual harmCorrected May 15, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Apr 52025

   Standard health inspection

   37 findings

   The same visit included a complaint investigation.

   • F695Provide safe and appropriate respiratory care for a resident when needed.Level JImmediate jeopardyCorrected May 15, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected May 15, 2025
   • 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.Level FNo actual harm, potential for moreCorrected May 15, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 15, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected May 15, 2025
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected May 15, 2025
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected May 15, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected May 15, 2025
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected May 15, 2025
   • F680Ensure the activities program is directed by a qualified professional.Level ENo actual harm, potential for moreCorrected May 15, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected May 15, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected May 15, 2025
   • 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.Level ENo actual harm, potential for moreCorrected May 15, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected May 15, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 15, 2025
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • 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.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected May 15, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • 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.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • 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.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • 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.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F809Ensure 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.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level DNo actual harm, potential for moreCorrected May 15, 2025
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level DNo actual harm, potential for moreCorrected May 15, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Mar 132025

   Complaint investigation

   6 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Apr 15, 2025
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Apr 15, 2025
   • F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Level FNo actual harm, potential for moreCorrected Apr 15, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 15, 2025
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Apr 15, 2025
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Apr 15, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Oct 12024

    Complaint investigation

    6 findings

    • F572Give residents a notice of rights, rules, services and charges.Level DNo actual harm, potential for moreCorrected Oct 30, 2024
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Oct 30, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Oct 30, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 30, 2024
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 30, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 30, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Aug 142024

    Complaint investigation

    3 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Sep 19, 2024
    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Sep 19, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Sep 19, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Jun 212024

    Complaint investigation

    3 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Jul 11, 2024
    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Jul 11, 2024
    • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Jul 11, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

13. May 242024

    Standard health inspection

    19 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jul 9, 2024
    • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • 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.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
    • F584Honor 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.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • 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.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
    • 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.Level DNo actual harm, potential for moreCorrected Jul 9, 2024

    Enforcement Action

    Civil money penalty, $168,384 imposed May 24, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 24, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $183,768 imposed March 13, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 24, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed March 13, 2025. Status: Closed, June 3, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 24, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

14. Mar 192024

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 24, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

15. Jan 102024

    Complaint investigation

    1 finding

    • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Jan 30, 2024

    Enforcement Action

    Civil money penalty, $3,418 imposed February 6, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of January 10, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

16. Nov 222023

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 28, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Six Inspections

   Inspectors cited F684 in November 2023, May 2024, October 2024, April 2025, April 2026 and July 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F684 across all 16 inspections, oldest to newest
2. 2

   Citation F607, Cited in Four Inspections

   Inspectors cited F607 in May 2024, August 2024, April 2025 and April 2026. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F607 across all 16 inspections, oldest to newest
3. 3

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in March 2024, June 2024, March 2025 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F689 across all 16 inspections, oldest to newest
4. 4

   Dialysis Care, Cited in Four Inspections

   Inspectors cited F698 in May 2024, April 2025, December 2025 and April 2026. This citation covers care for residents who need dialysis. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F698 across all 16 inspections, oldest to newest
5. 5

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in May 2024, October 2024, April 2025 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F880 across all 16 inspections, oldest to newest
6. 6

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in May 2024, April 2025 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F686 across all 16 inspections, oldest to newest
7. 7

   Continence and Catheter Care, Cited in Three Inspections

   Inspectors cited F690 in May 2024, April 2025 and April 2026. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F690 across all 16 inspections, oldest to newest
8. 8

   Respiratory Care, Cited in Three Inspections

   Inspectors cited F695 in May 2024, April 2025 and April 2026. This citation covers oxygen, breathing treatments and other respiratory care. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F695 across all 16 inspections, oldest to newest
9. 9

   Citation F730, Cited in Three Inspections

   Inspectors cited F730 in May 2024, April 2025 and April 2026. The agency describes it this way: Observe each nurse aide's job performance and give regular training. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242424252525252526262626F730 across all 16 inspections, oldest to newest
10. 10

    Citation F756, Cited in Three Inspections

    Inspectors cited F756 in May 2024, April 2025 and April 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F756 across all 16 inspections, oldest to newest
11. 11

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in May 2024, April 2025 and April 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F761 across all 16 inspections, oldest to newest
12. 12

    Citation F803, Cited in Three Inspections

    Inspectors cited F803 in May 2024, April 2025 and April 2026. The agency describes it this way: 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. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F803 across all 16 inspections, oldest to newest
13. 13

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in May 2024, April 2025 and April 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F812 across all 16 inspections, oldest to newest
14. 14

    Administration, Cited in Three Inspections

    Inspectors cited F835 in June 2024, March 2025 and July 2026. This citation covers whether the home is run in a way that uses its resources effectively. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F835 across all 16 inspections, oldest to newest
15. 15

    Antibiotic Use, Cited in Three Inspections

    Inspectors cited F881 in May 2024, April 2025 and April 2026. This citation covers the home’s program for monitoring antibiotic use. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F881 across all 16 inspections, oldest to newest
16. 16

    Protection From Abuse and Neglect, Cited in Two Inspections

    Inspectors cited F600 in August 2024 and April 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F600 across all 16 inspections, oldest to newest
17. 17

    Citation F620, Cited in Two Inspections

    Inspectors cited F620 in April 2025 and April 2026. The agency describes it this way: Not 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F620 across all 16 inspections, oldest to newest
18. 18

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in October 2024 and April 2025. This citation covers whether the home’s services meet professional standards of quality. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F658 across all 16 inspections, oldest to newest
19. 19

    Citation F660, Cited in Two Inspections

    Inspectors cited F660 in June 2024 and March 2025. The agency describes it this way: Plan the resident's discharge to meet the resident's goals and needs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F660 across all 16 inspections, oldest to newest
20. 20

    Citation F726, Cited in Two Inspections

    Inspectors cited F726 in May 2024 and April 2025. The agency describes it this way: 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. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F726 across all 16 inspections, oldest to newest
21. 21

    Citation F840, Cited in Two Inspections

    Inspectors cited F840 in April 2025 and December 2025. The agency describes it this way: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F840 across all 16 inspections, oldest to newest
22. 22

    Citation F882, Cited in Two Inspections

    Inspectors cited F882 in May 2024 and April 2025. The agency describes it this way: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F882 across all 16 inspections, oldest to newest
23. 23

    Citation F944, Cited in Two Inspections

    Inspectors cited F944 in April 2025 and April 2026. The agency describes it this way: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242424252525252526262626F944 across all 16 inspections, oldest to newest
24. 24

    A Clean, Homelike Setting, No Recorded Correction

    F584 was cited in May 2024, April 2025, January 2026 and August 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23242424242424252525252526262626F584 across all 16 inspections, oldest to newest
25. 25

    Reporting Suspected Abuse, No Recorded Correction

    F609 was cited in April 2025 and August 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23242424242424252525252526262626F609 across all 16 inspections, oldest to newest
26. 26

    Investigating Alleged Violations, No Recorded Correction

    F610 was cited in May 2024, August 2024, March 2025, April 2026 and August 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23242424242424252525252526262626F610 across all 16 inspections, oldest to newest
27. 27

    Nursing Staff Levels, No Recorded Correction

    F725 was cited in April 2025 and August 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23242424242424252525252526262626F725 across all 16 inspections, oldest to newest
28. 28

    Pharmacy Services, No Recorded Correction

    F755 was cited in April 2025 and August 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23242424242424252525252526262626F755 across all 16 inspections, oldest to newest
29. 29

    Significant Medication Errors, No Recorded Correction

    F760 was cited in October 2024, April 2025 and August 2026. This citation covers whether residents are free from significant medication errors. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23242424242424252525252526262626F760 across all 16 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in six inspections, most seriously at level E.

2. 02

   What changed after F607 was cited, and how do you check it now?

   Citation F607: cited in four inspections, most seriously at level D.

3. 03

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in four inspections, most seriously at level K.

4. 04

   How is dialysis care coordinated, and who monitors residents before and after treatment?

   Dialysis Care: cited in four inspections, most seriously at level E.

5. 05

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in four inspections, most seriously at level F.

6. 06

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in three inspections, most seriously at level D.

7. 07

   How is continence care scheduled, and how do you prevent urinary infections?

   Continence and Catheter Care: cited in three inspections, most seriously at level D.

8. 08

   Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

   Respiratory Care: cited in three inspections, most seriously at level J.

9. 09

   What changed after F730 was cited, and how do you check it now?

   Citation F730: cited in three inspections, most seriously at level E.

10. 10

    What changed after F756 was cited, and how do you check it now?

    Citation F756: cited in three inspections, most seriously at level E.

11. 11

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in three inspections, most seriously at level D.

12. 12

    What changed after F803 was cited, and how do you check it now?

    Citation F803: cited in three inspections, most seriously at level F.

13. 13

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in three inspections, most seriously at level F.

14. 14

    How long have the administrator and the director of nursing been in their roles?

    Administration: cited in three inspections, most seriously at level F.

15. 15

    How do you track antibiotic use and decide when one is needed?

    Antibiotic Use: cited in three inspections, most seriously at level F.

16. 16

    What happened after the abuse or neglect citation, and what changed in training or supervision?

    Protection From Abuse and Neglect: cited in two inspections, most seriously at level G.

17. 17

    What changed after F620 was cited, and how do you check it now?

    Citation F620: cited in two inspections, most seriously at level D.

18. 18

    How do you check that nurses and aides follow professional standards, and what happens when they do not?

    Professional Standards: cited in two inspections, most seriously at level G.

19. 19

    What changed after F660 was cited, and how do you check it now?

    Citation F660: cited in two inspections, most seriously at level D.

20. 20

    What changed after F726 was cited, and how do you check it now?

    Citation F726: cited in two inspections, most seriously at level E.

21. 21

    What changed after F840 was cited, and how do you check it now?

    Citation F840: cited in two inspections, most seriously at level D.

22. 22

    What changed after F882 was cited, and how do you check it now?

    Citation F882: cited in two inspections, most seriously at level F.

23. 23

    What changed after F944 was cited, and how do you check it now?

    Citation F944: cited in two inspections, most seriously at level F.

24. 24

    What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

    A Clean, Homelike Setting: cited in four inspections, most seriously at level D. The August 24, 2026 citation has no recorded correction date.

25. 25

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in two inspections, most seriously at level D. The August 24, 2026 citation has no recorded correction date.

26. 26

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in five inspections, most seriously at level D. The August 24, 2026 citation has no recorded correction date.

27. 27

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Nursing Staff Levels: cited in two inspections, most seriously at level E. The August 24, 2026 citation has no recorded correction date.

28. 28

    How often does the consultant pharmacist review each resident’s medications?

    Pharmacy Services: cited in two inspections, most seriously at level E. The August 24, 2026 citation has no recorded correction date.

29. 29

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in three inspections, most seriously at level D. The August 24, 2026 citation has no recorded correction date.

30. 30

    What led to the 2026 fine, and has it been paid?

    A $27,378 civil money penalty was imposed April 15, 2026. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Pennsylvania state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Nov 22, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Jan 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Mar 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection May 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Jun 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Aug 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Oct 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Mar 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Apr 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Apr 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection May 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Dec 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Jan 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Apr 10, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Jul 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Pennsylvania state survey agency

  Inspection Aug 24, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 395883

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.