Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Ball Pavilion, The during CMS and state inspections, most recent first.
Expired food was found stored in a kitchen cooler and in pantry refrigerator/freezers, including dated iced tea, frozen chicken breasts, yogurt cups, and frozen hamburger patties. The Dietary Manager confirmed the items were past their use-by or expiration dates and that some at-your-service items were beyond the 30-day limit. A resident's personal refrigerator also had no temperature log sheet, and the NHA confirmed there was no evidence of temperature monitoring.
An RN and LPNs failed to follow EBP and hand hygiene practices during medication administration for residents with IV and g-tube devices. Staff did not don gowns for IV and g-tube care, turned off a faucet with a bare hand instead of using a towel, and handled oral meds with bare hands while preparing doses for two residents.
Failure to Send Required Transfer Information: The facility did not document that necessary clinical information was communicated to the receiving provider when three residents were transferred. The residents had significant medical histories, including CVA, anxiety, HTN, GERD, depression, muscle weakness, acute respiratory failure, HF, and dementia, and the DON confirmed the records lacked evidence that the required transfer information had been provided.
Failure to Review and Revise Care Plans: The facility did not review and/or revise the care plans for two residents as required. One resident had GERD, depression, and muscle weakness, and most of the care plans had overdue target dates; the other resident had diabetes, kidney disease, and HTN, with several care plans also past their target dates. The RN Assessment Coordinator confirmed the care plans were not reviewed and/or revised as required.
Failure to Follow Nursing Standards for Admission Assessment and Medication Administration: An LPN completed a resident's admission assessment and baseline care plan, and during medication administration to another resident with spinal conditions, the LPN left oral medications on a tray table after observing only the nasal spray being self-administered. The resident's record lacked evidence of a self-medication assessment, care plan, or physician order permitting self-administration, and the DON confirmed medications should not be left in resident rooms.
Improper Storage of Oxygen Tubing: A resident receiving O2 via concentrator/portable at 2 L/min was observed with portable tubing hanging over the top of the canister attached to the wheelchair, rather than stored as required when not in use. An LPN confirmed the tubing should not be left hanging over the canister, and the Infection Control nurse confirmed the concentrator tubing should be hung on the wall hook when not in use.
Expired medications were found stored in two areas of the facility: a multi-dose vial of Tubersol in a med room refrigerator and a multi-dose vial of Humalog in a med cart. An LPN confirmed both vials were expired and should have been discarded, despite facility policy requiring expired meds to be removed from stock and disposed of promptly.
Incomplete documentation of g-tube feeding and flushes. A resident with dementia, pneumonitis, and gastrostomy status had orders for enteral nutrition by pump and scheduled water flushes, but staff documented only that the feeding was hung and removed and did not record the amount of formula received or the amount of water administered in 24 hours. The DON confirmed the MAR and clinical record were incomplete and inaccurate.
The facility did not complete monthly pharmacy drug regimen reviews for five residents, as required by their contract and policy. The clinical records lacked evidence of reviews for three months, and the RNAC confirmed the absence of a Pharmacy Consultant during this period.
A facility failed to implement a side-to-side offloading program for a resident with a partial thickness MASD on the left buttock, as recommended by a wound care specialist. Despite orders for offloading, there was no evidence of a physician's order or documentation in the care plan, leading to the deterioration of the wound. The resident required varying levels of assistance for mobility, and the RN Assessment coordinator confirmed the need for the offloading program.
The facility failed to ensure accurate MDS assessments for three residents. One resident's MDS was incorrectly coded for a Stage Three ulcer, while documentation showed a partial thickness MASD wound. Another resident's MDS inaccurately recorded a Stage Four ulcer as not present on admission, despite evidence it was not acquired at the facility. A third resident's MDS showed a Stage Three ulcer, but records indicated a partial thickness MASD wound. The inaccuracies were confirmed by the RN Assessment Coordinator.
Expired Food Stored in Refrigerators and No Temperature Log for Personal Refrigerator
Penalty
Summary
The facility failed to ensure that food was stored in accordance with food safety standards in one kitchen refrigerator and in three pantry refrigerator/freezers. During a kitchen tour, two pitchers of iced tea were observed in cooler six with a date of 3/17/26, and the Dietary Manager confirmed they were past the use-by date and should have been discarded. In the A Hall pantry refrigerator/freezer, three frozen prepared individually wrapped chicken breasts dated 10/22/25 were observed, and the Dietary Manager confirmed they were expired and should be discarded; he/she also stated they were an at-your-service item that should be discarded if not used within 30 days. In the C Hall pantry refrigerator/freezer, expired single-serve yogurt cups and frozen prepared hamburger patties were observed, including yogurt cups with expiration dates of 2/5/26, 2/17/26, 3/9/26, 3/17/26, and 3/19/26, along with hamburger patties dated 2/10/26 and 10/23/25. In the B Hall pantry refrigerator/freezer, frozen prepared hamburger patties dated 2/10/26 and 2/20/26 were observed. The Dietary Manager confirmed the yogurt cups and hamburger patties were expired and should be discarded, and confirmed the hamburger patties were at-your-service items subject to the 30-day discard rule. The facility also failed to monitor a resident's personal refrigerator for temperatures; Resident R55 had a personal refrigerator in the room, but no temperature log sheet was present, and the Nursing Home Administrator confirmed there was no evidence of temperature monitoring.
Cross Contamination During Medication Administration
Penalty
Summary
The facility failed to prevent potential cross contamination during medication administration for four residents. Resident R52 had diagnoses including pleural effusion, pneumonia, kidney disease, and irregular heartbeat, and had physician orders for enhanced barrier precautions due to a PICC line and for IV cefazolin sodium through a venous catheter. During observation, an RN administered IV medication through the PICC line while wearing gloves but did not don a gown despite EBP signage outside the room indicating gowns and gloves were required for high-contact care. For Resident R49, who had dementia, pneumonitis, and gastrostomy status with an order for enhanced barrier precautions due to a g-tube, an LPN washed hands and then turned off the spigot with a bare hand before donning gloves and administering medications through the g-tube, and did not don a gown. During medication administration for Resident R15, the same LPN handled loose tablets with a bare hand while preparing medications, and for Resident R63, another LPN removed a soft gel cap medication from the pharmacy bottle with a bare hand and placed it in a medication cup. The DON confirmed gowns should be worn during IV and g-tube medication administration and that medications should not be handled with bare hands, and the Infection Preventionist confirmed staff should use a towel to turn off the spigot and wear gowns during IV or g-tube medication administration.
Failure to Send Required Clinical Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when residents were transferred to another setting. Facility policy for transfer to the hospital required the nurse to inform the emergency department of the transfer and send necessary paperwork and notifications, including the face sheet, living will if present, out-of-facility DNR, resident transfer sheet, vaccine records, and other relevant clinical records. Clinical records showed that Resident R4, admitted with diagnoses including cerebral infarction, anxiety, and high blood pressure, was transferred to the hospital after a progress note dated 12/6/25, but the record lacked evidence that necessary clinical information was sent. Resident R5, admitted with GERD, depression, and muscle weakness, was transferred to the hospital after a progress note dated 1/29/26, and the record also lacked evidence of communication of necessary clinical information. Resident R62, admitted with acute respiratory failure, heart failure, and dementia, was transferred to assisted living after a progress note dated 3/6/26, and the record likewise lacked evidence that necessary clinical information was provided to the receiving health care provider. During interview, the DON confirmed that the records lacked evidence that the required clinical information had been provided at the time of transfer.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and/or revise the care plans for two residents whose comprehensive care plans had outstanding target dates past the review date. Facility policy stated that the interdisciplinary team would formulate goals and approaches after identifying resident problems or conditions, that goals should be measurable and time-framed, and that periodic reviews and revisions would be completed. On 3/25/26, review of Resident R5’s record showed an admission date of 7/8/24 and diagnoses including GERD, depression, and muscle weakness. Of the 31 care plans present, 28 had an outstanding target date of 12/31/25 and two had an outstanding target date of 3/4/26. The care plans included multiple problem categories such as anticoagulant therapy, diuretic therapy, CHF, risk for dehydration, risk for infection, risk for malnutrition, pressure ulcer, ROM, antidepressant medication, enhanced barrier precautions, risk for UTI, cognition, UTI, pain, treatment, decreased cardiac output, personalized care, wound management, depression, pain control, EBP related to ESBL, impaired physical mobility, coping, sensory perception, self-care, risk for bleeding, altered fluid balance, skin integrity, cardiac function, and fluid restriction. Review of Resident R55’s record on 3/25/26 showed an admission date of 10/30/25 and diagnoses including diabetes, kidney disease, and high blood pressure. Of the nine care plans present, six had an outstanding target date of 11/19/25. The care plans included personalized care, risk for UTI, psychosocial wellbeing, skin tear, discharge planning, and pain. During an interview on 3/25/26 at 2:15 p.m., the RN Assessment Coordinator confirmed that Resident R5 and Resident R55’s care plans were not reviewed and/or revised as required.
Failure to Follow Nursing Standards for Admission Assessment and Medication Administration
Penalty
Summary
The facility failed to provide services that adhered to accepted standards of practice for Resident R63 during medication administration. Resident R63 was admitted with diagnoses including spinal stenosis, spondylolisthesis, and radiculopathy of the middle back. The clinical record lacked evidence of a self-medication assessment, a care plan, or a physician's order allowing the resident to administer his/her own medications. During observation, an LPN prepared and delivered medications to the resident, observed the resident self-administer nasal spray, and then left the resident's oral medications sitting on the tray table while exiting the room. The LPN stated that because the resident was alert and oriented times four, it was okay to leave the medications for the resident to take. The facility also failed to ensure Resident R1's admission assessment and baseline care plan were completed by appropriate nursing staff. Resident R1 was admitted with diagnoses including bacterial pneumonia, spinal stenosis, high blood pressure, and vertigo. The admission assessment and departmental admission progress note indicated that the assessment was completed by an LPN, and interviews with the RN, Infection Preventionist, and RN Assessment Coordinator confirmed that both the admission assessment and baseline care plan were completed by an LPN.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to appropriately maintain respiratory care equipment to prevent the spread of infection for one resident receiving oxygen therapy. A facility policy dated 2/19/26 stated that oxygen tubing is to be hung on the wall with a specific label when not in use and/or changed to portable oxygen delivery. The resident’s clinical record showed an admission date of 2/27/26 and diagnoses including congestive heart failure, spinal stenosis of the neck and mid-back, and high blood pressure. A physician’s order dated 2/27/26 directed oxygen via oxygen concentrator/portable at 2 liters per minute every shift. On 3/24/26 at 1:00 p.m., the resident was observed sitting in the room with concentrator tubing in the nose while the portable oxygen cannula tubing was hanging over the top of the canister attached to the back of the wheelchair. An LPN confirmed that the tubing for the portable canister should not be hanging over the top of the canister on the back of the wheelchair. On 3/25/26 at 11:10 a.m., the resident was again observed in the wheelchair with the concentrator tubing in the nose and the portable oxygen tubing hanging over the top of the canister attached to the wheelchair. Later that morning, the concentrator tubing was observed lying on top of the bed while the resident was no longer in the room, and the Infection Control nurse confirmed that the tubing should be hanging on the hook on the wall when not in use.
Expired Medications Found in Refrigerator and Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles when an outdated multi-dose vial of Tubersol was found in the Unit B medication room refrigerator and an outdated multi-dose vial of Humalog insulin was found in a Unit A-1 medication cart. Facility policy stated that outdated medications are to be immediately removed from stock and disposed of according to medication destruction procedures, and that the nighttime nurse is to complete the medication cart check sheet daily and remove expired medications. During observation, a Tubersol vial in the Unit B refrigerator had an expiration date of 3/22/26, and an LPN confirmed it was expired and should have been discarded. During a separate observation, a Humalog vial in the Unit A-1 medication cart had an expiration date of 3/18/26, and an LPN confirmed it was expired and should have been discarded.
Incomplete Documentation of G-Tube Feeding and Flushes
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a gastrostomy tube. Resident R49 had diagnoses including dementia, pneumonitis, and gastrostomy status, and had physician orders for enteral nutrition via pump at 80 cc/hr from 6:00 p.m. to 6:00 a.m. and for tube flushes with 140 cc of water every 4 hours, plus 30 cc before and after each medication administration. The facility policy on transcribing physician's orders stated that enteral feeding orders must include the amount delivered to the resident and the amount of water in a 24-hour period, if indicated by the physician. The resident's MAR showed staff documented that the feeding was hung at 6:00 p.m. and removed at 6:00 a.m., but did not record the amount of feeding received. The MAR also documented the ordered water flushes, but did not record the amount of water administered in a 24-hour period. A dietitian note stated the feeding regimen was intended to provide 1500 calories, 69 gm protein, and 1573 cc total water, but the clinical record lacked evidence that these nutritional needs were being met or that staff were recording the amount of nutritional feeding and water provided. The DON confirmed during interview that the record contained incomplete and inaccurate documentation regarding tube feeding amounts and flushes.
Failure to Conduct Monthly Pharmacy Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly pharmacy drug regimen reviews were completed for five residents, as required by their contract and policy. The Care Apothecary Consultant Pharmacy Retainer Agreement stipulated that monthly reviews of each resident's drug regimen would be conducted, with recommendations and assessments provided to the administrator. However, the clinical records for residents with various diagnoses, including Parkinson's Disease, dementia, and Alzheimer's, lacked evidence of these reviews for the months of October, November, and December 2024. During an interview, the Registered Nurse Assessment Coordinator confirmed that the pharmacy did not provide a Pharmacy Consultant to conduct the required monthly reviews during the specified months. This deficiency was identified through a review of the facility's contract, policy, clinical records, and staff interviews, indicating a failure to comply with the established guidelines for pharmacy services and management as per the relevant Pennsylvania Code sections.
Failure to Implement Wound Care Interventions
Penalty
Summary
The facility failed to provide appropriate care for a resident with a partial thickness moisture-associated skin damage (MASD) on the left buttock. The wound was initially assessed on 8/19/24 and showed improvement over time until 2/17/25, when it began to deteriorate. Despite the wound care specialist's orders for side-to-side offloading while in bed, there was no evidence of a physician's order for this intervention in the resident's clinical record. Additionally, the care plan for potential/actual impairment to skin integrity lacked documentation of the side-to-side offloading intervention, and there was no evidence that the resident received this care. The resident, who was admitted with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure, required varying levels of assistance for mobility as documented in the Minimum Data Set (MDS). The Registered Nurse Assessment coordinator confirmed that the resident should have had an offloading program in place to prevent the worsening of the wound. The lack of implementation of the recommended offloading intervention contributed to the deterioration of the resident's wound, indicating a failure to adhere to professional standards of practice for pressure ulcer care.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. Resident 35's MDS was incorrectly coded as having a Stage Three pressure ulcer, while documentation from a wound care specialist indicated the presence of a partial thickness moisture-associated skin damage (MASD) wound. Similarly, Resident 51's MDS inaccurately recorded a Stage Four pressure ulcer as not present on admission, despite specialist documentation confirming it was not acquired at the facility. Resident 52's MDS assessments were also inaccurately coded, showing a Stage Three pressure ulcer, whereas the wound care specialist's records described a partial thickness MASD wound that was initially improving but later deteriorated. The Registered Nurse Assessment Coordinator confirmed the incorrect wound staging on the MDS for all three residents during an interview. These inaccuracies in the MDS assessments were identified as deficiencies in the facility's compliance with regulatory requirements.
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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 Erie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twinbrook Healthcare And Rehabilitation Center | 2 mi | ★★★★★ | 20 | 0 |
| Pennsylvania Soldiers And Sailors Home | 4.8 mi | ★★★★★ | 9 | 0 |
| Nightingale Nursing And Rehab Center | 5.1 mi | ★★★★★ | 9 | 0 |
| Lecom At Village Square, Llc | 5.9 mi | ★★★★★ | 3 | 0 |
| Sarah Reed Senior Living | 6 mi | ★★★★★ | 4 | 0 |
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