Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth-town Center during CMS and state inspections, most recent first.
A resident with a history of lumbar fusion and moderate pain management needs did not receive all prescribed doses of Oxycodone during a night shift. Investigation found that a nurse signed out four doses but failed to document administration and later admitted to diverting two tablets for personal use, resulting in the resident not receiving adequate pain control.
The facility did not timely or fully report allegations of physical abuse and medication misappropriation involving two residents. In both cases, notifications to law enforcement and Adult Protective Services were either not made or not documented, and required reporting to the State Agency was delayed or incomplete. Staff interviews revealed confusion about reporting responsibilities and regulatory time frames.
A resident with diabetes did not receive prescribed 70/30 insulin doses on time or at all on several occasions, resulting in elevated blood sugar levels. Nursing staff did not notify the physician about the missed or late insulin administrations, despite facility expectations and the physician's stated need for immediate notification in such cases.
A resident with diabetes did not receive prescribed Humulin 70/30 insulin as ordered, with doses given late or missed entirely due to medication unavailability and delayed administration practices. Blood sugar levels were significantly elevated during these incidents, and the physician was not notified of the missed or late doses as required. Nursing staff cited following room order and lack of backup insulin as contributing factors.
A resident with severe cognitive impairment and Parkinson's disease fell out of bed during incontinence care, resulting in a forehead laceration and a C-1 fracture. The incident occurred when the resident kicked out his leg while being turned by a nursing assistant, who was providing one-person assistance. The resident was transported to the hospital for evaluation and treatment, and his care plan was subsequently updated to require two-person assistance for all activities of daily living.
The facility failed to post required oxygen safety signs for residents receiving oxygen therapy, despite their medical conditions necessitating such precautions. Observations showed that rooms lacked signage, and interviews revealed staff were unaware of the requirement. Facility leadership misunderstood the policy, believing no smoking signs at entrances sufficed.
During a kitchen inspection, several deficiencies were identified, including a dented can of spaghetti sauce not removed from storage, open bags of frozen food in the freezer, and wet steamer pans stacked improperly. Additionally, staff members were observed with uncovered facial hair while in the kitchen, contrary to facility standards. These issues were acknowledged by the Dietary Manager and staff, who were unsure why proper procedures were not followed.
The facility failed to notify a resident and relevant parties of a hospital transfer due to shortness of breath, as no transfer letter was documented. The SW was unaware of the requirement to send such letters. Additionally, the facility did not send discharge and transfer summaries to the Ombudsman, who reported not receiving them for several months. The SW admitted to not sending these summaries in 2024, citing being behind in tasks.
A facility failed to accurately code a resident's MDS assessment, omitting the resident's moderate hearing difficulty and use of bilateral hearing aids. Despite observations and staff interviews confirming the resident's need for hearing aids, the MDS assessment did not reflect this, contrary to RAI manual requirements.
Misappropriation of Controlled Pain Medication by Staff
Penalty
Summary
A resident with lumbar stenosis and a history of lumbar fusion was admitted with orders for Oxycodone 5mg to be administered every four hours as needed for moderate pain. The resident was cognitively intact and on a scheduled pain regimen. On one occasion, the resident reported not receiving her morning pain medication as requested, despite documentation by a nurse indicating that four doses of Oxycodone were signed out during the night shift. However, the Medication Administration Record did not show that the medication was administered to the resident on the relevant dates. An investigation revealed that the nurse responsible for the resident's care admitted to diverting two Oxycodone tablets for personal use. The nurse had signed out four doses but failed to document administration on the MAR, and the resident confirmed not receiving all prescribed doses during the shift. The incident was reported to the state and the nursing board, and the nurse was subsequently terminated. Interviews with facility staff and the resident corroborated the misappropriation of the controlled medication.
Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation in a timely and complete manner for two residents. In the first case, a resident reported that a man had entered his room and physically assaulted him. The allegation was reported to the Director of Nursing (DON) and the State Agency was notified via fax, but there was no documentation that law enforcement or Adult Protective Services (APS) were contacted. Both the current and previous administrators, as well as the previous DON, confirmed that notifications to law enforcement and APS were not made, and these actions were not documented on the required forms. In the second case, a resident alleged that her morning pain medication was not administered, which was later substantiated as misappropriation by a nurse who was subsequently terminated. The initial allegation report was faxed to the State Agency and local law enforcement was notified, but this was not done within the required time frame. There was also no documentation that APS was notified regarding the misappropriation. Interviews with the previous administrator and DON revealed uncertainty about who was responsible for contacting APS and law enforcement, and the DON was unable to recall the regulatory time frames for reporting such incidents. Throughout both incidents, there was a lack of clarity and follow-through regarding the facility's internal processes for reporting abuse and misappropriation allegations. Staff interviews indicated confusion about roles and responsibilities for making required notifications, and documentation was incomplete or missing for critical steps in the reporting process. The required notifications to law enforcement and APS were either not made or not documented, resulting in a failure to meet regulatory requirements for timely and complete reporting.
Failure to Notify Physician of Missed or Late Insulin Administration
Penalty
Summary
Facility staff failed to notify the physician when a resident's prescribed 70/30 insulin was not administered or was administered late. The resident, who had a diagnosis of diabetes, had physician orders for Humulin 70/30 insulin to be given twice daily with blood sugar checks prior to administration. On multiple occasions, the insulin was either given late or not given at all, with blood sugar readings significantly above the normal range. Specifically, the insulin was administered several hours late on two occasions and was not administered at all on another occasion due to a delay in pharmacy delivery. Documentation on the Medication Administration Record (MAR) reflected these late or missed doses and the associated high blood sugar values. Nursing staff interviews revealed that the insulin was administered late due to the nurse's medication administration routine and that the physician was not notified when the insulin was missed or delayed. The DON confirmed that the expectation was for nurses to inform leadership and the physician if medications, particularly insulin, were not given on time. The physician stated he was not notified of the missed or late doses and would have expected immediate notification, especially given the resident's elevated blood sugar levels and the importance of timely insulin administration.
Failure to Administer Insulin as Ordered and Adhere to Medication Timing
Penalty
Summary
A significant medication error occurred when a resident with diabetes and hypertension did not receive their prescribed Humulin 70/30 insulin as ordered by the physician. The resident's orders specified 90 units of insulin to be administered at 8:00AM and 5:00PM, with blood sugars checked beforehand. On multiple occasions, the insulin was either administered late or not given at all. Specifically, the morning dose on one day was given over four hours late, and the evening dose on another day was omitted entirely due to the medication not being available from the pharmacy. Additionally, another morning dose was administered two hours late. Blood sugar readings at these times were significantly elevated, with values of 405, 420, and 549 mg/dl recorded. The resident's care plan included monitoring for signs of hyperglycemia and hypoglycemia, and the physician expected to be notified of any missed or late doses, which did not occur. Interviews with nursing staff revealed that medication administration was delayed due to following room order rather than medication timing, and that the pharmacy was not contacted in a timely manner to ensure insulin availability. The DON confirmed that there was no backup supply of Humulin 70/30 insulin in the facility and that nurses should have informed leadership if medications were not given on time. The physician stated it was unacceptable to administer 70/30 insulin after breakfast and expected to be notified of any missed or late doses, which did not happen. The resident and family also reported concerns about not receiving insulin before meals as ordered.
Resident Falls During Incontinence Care
Penalty
Summary
The facility failed to provide care in a safe manner when a resident, who was severely cognitively impaired and required substantial to maximum assistance for bed mobility and incontinence care, fell out of bed during incontinence care. The resident, who had been admitted with diagnoses including Parkinson's disease, sustained a laceration to the right side of his forehead requiring six sutures and a C-1 fracture that necessitated the long-term use of a cervical collar for neck support. The incident occurred when a nursing assistant was providing incontinence care and the resident kicked out his leg, causing him to roll out of the bed. The nursing assistant involved in the incident reported that she had been providing care to the resident, who was previously assessed as needing one-person assistance for bed mobility and incontinence care. During the care, the resident was turned onto his left side, and despite the nursing assistant's attempt to secure him, he rolled out of the bed. The nursing assistant called for help, and a nurse arrived to find the resident on the floor with a significant amount of blood under his head. Emergency Medical Services were called, and the resident was transported to the hospital for evaluation. Hospital records confirmed the resident had a laceration and a nondisplaced fracture of the C1 vertebra. Following the incident, the resident's care plan was updated to require two-person assistance for all activities of daily living, including bed mobility and incontinence care. The facility's physician acknowledged the seriousness of the accident and noted that the resident could have been more seriously injured.
Failure to Post Oxygen Safety Signs for Residents
Penalty
Summary
The facility failed to post precautionary and safety signs indicating the use of oxygen for five residents who required respiratory care. Observations revealed that residents receiving continuous oxygen therapy did not have the necessary signage in their rooms or on their doors, which is a requirement for safety and precautionary measures. This deficiency was noted for residents with various diagnoses, including chronic obstructive pulmonary disease (COPD), congestive heart failure, and pneumonia, all of whom were receiving oxygen therapy as part of their treatment plan. Interviews with nursing staff, including nurses and nurse assistants, indicated a lack of awareness and understanding regarding the requirement to post oxygen safety signs. Nurse #2 and Nurse Assistant #1 both admitted to not being aware of the missing signs, while Nurse #4 acknowledged that signs were supposed to be posted at admission but could not explain why they were absent. The Director of Nursing also confirmed that it was the nurses' responsibility to ensure signage was posted, yet some rooms were missed. The facility's leadership, including the Director of Nursing and the Area President, believed that posting no smoking signs at the facility's entrance and exit doors was sufficient, and individual room signage was not necessary. This misunderstanding contributed to the oversight, as the policy was incorrectly interpreted, leading to the absence of required oxygen safety signs in the rooms of residents using oxygen therapy.
Kitchen Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility was found to have several deficiencies during a kitchen inspection. A dented can of spaghetti sauce was discovered on the rack of canned goods, which should have been removed and placed on a designated shelf for dented cans. The Assistant Dietary Manager was unable to explain why the can had not been removed. Additionally, the freezer contained open boxes of beef patties, cube steak, and fish nuggets, with the plastic bags inside left open to air. Staff members, including [NAME] #1 and the Dietary Manager, acknowledged that the bags should have been closed but were unsure why they were left open. Further observations revealed that five steamer pans were stacked while still wet, contrary to the requirement that dishes be air-dried before storage. The Assistant Dietary Manager could not provide a reason for this oversight. During a subsequent kitchen tour, both the Dietary Manager and a Dietary Aide were noted to have uncovered facial hair, with the Dietary Aide serving food without covering his facial hair. The Dietary Manager mistakenly believed that facial hair coverings were only necessary during direct food preparation. Interviews with the Registered Dietitian and kitchen staff confirmed these practices were not in compliance with the facility's standards.
Failure to Notify Residents and Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to provide timely notification to residents and relevant parties regarding transfers and discharges. Specifically, for one resident who was transferred to the hospital for evaluation due to shortness of breath, there was no letter of transfer or discharge documented in the medical record. The Social Worker (SW) admitted during an interview that the facility had not been sending these letters to residents who were transferred to the hospital or discharged, as she was unaware of the requirement. The Senior Nurse Consultant confirmed that it was the facility's policy to send such letters. Additionally, the facility did not send a summary of discharge and transfer information to the Ombudsman. Another resident was transferred to the hospital for complications of post-hemorrhagic anemia and later readmitted to the facility. The Ombudsman reported not receiving monthly reports of facility transfers or discharges for several months. The SW acknowledged that she had not sent any transfer or discharge summaries to the Ombudsman in 2024 and had only recently faxed the lists from January to May 2024. The SW could not provide a reason for the delay other than being behind in tasks.
Inaccurate MDS Coding for Resident's Hearing Ability
Penalty
Summary
The facility failed to accurately code the significant change in status Minimum Data Set (MDS) assessments for a resident. The resident was readmitted with diagnoses including cognitive communication deficit and cerebral vascular accident (CVA). An observation report indicated the resident had moderate difficulty hearing and used bilateral hearing aids. However, the most recent MDS significant change assessment did not reflect the resident's moderate hearing ability or the use of hearing aids, as required by the Resident Assessment Instrument (RAI) manual. Observations confirmed the resident wore bilateral hearing aids, and interviews with nursing staff revealed the resident always needed them to hear adequately. The MDS nurses stated that residents were coded based on assessments during the MDS assessment look-back period, but the coding did not accurately reflect the resident's condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harrisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gardens Of Taylor Glen Retirement Community | 5.7 mi | ★★★★★ | 1 | 0 |
| University Place Nursing And Rehabilitation Center | 5.9 mi | ★★★★★ | 2 | 0 |
| Crown Haven Health And Rehabilitation | 8 mi | ★★★★★ | 0 | 0 |
| Cabarrus Health And Rehabilitation Center | 8 mi | ★★★★★ | 2 | 0 |
| Clear Creek Nursing & Rehabilitation Center | 8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.