Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Crosslands during CMS and state inspections, most recent first.
The facility did not follow its own Criminal Record/FBI Check Policy when hiring a staff member who had not been a state resident for the required two-year period. Policy required an FBI national criminal background check for such individuals upon hire, but review of the employee’s personnel file showed no evidence that an FBI check was initiated or completed. The NHA confirmed that the employee did not meet the two-year residency requirement and that the FBI check had not been done, resulting in a failure to properly screen the individual for findings of abuse, neglect, exploitation, or theft before employment.
A resident discharged to independent living did not have proper documentation of medication disposition completed at discharge. Facility policy required the licensed nurse to remove all medications from the med cart, count remaining quantities, and document the amounts and disposition on a printed eMAR or in an ID note, then ensure it was entered into the EHR. For this resident, the nurse discharge summary only stated that all medications were given to the resident, without recording the quantities of medications. The DON later confirmed that the required documentation of medication disposition was not completed, resulting in a failure to follow the facility’s clinical records policy.
A resident's care plan for continence was not followed, leading to a fall and injury. The resident, who was supposed to be toileted at specific intervals, was last toileted at 9:00 a.m. and later found on the floor with a hematoma. The facility's documentation and staff interviews confirmed the care plan was not adhered to, resulting in the fall.
A resident fell from a Broda chair, sustaining a hematoma and other symptoms, due to the facility's failure to follow the resident's toileting care plan. Despite the incident and the facility's policy requiring investigation of suspected abuse or neglect, no investigation was conducted.
A facility failed to ensure accurate assessments for a resident, as the discharge MDS indicated an incorrect discharge location. The resident was marked as discharged to an acute hospital, but records showed they were discharged home. This error was confirmed by the RNAC during an interview.
The facility failed to notify physicians in a timely manner of multiple medication errors experienced by 15 residents. The errors, originating from the contracted pharmacy, were identified through internal audits. Despite the findings, attending physicians were not informed until much later, as confirmed by the DON and NHA.
The facility failed to address pharmacy delivery errors, resulting in 70 medication errors for 15 residents. These errors were due to late deliveries from the contracted pharmacy, leading to missed doses of critical medications for conditions such as pain, glaucoma, calcium deficiency, insomnia, and more. The facility is now seeking a new pharmacy to meet residents' needs.
Failure to Obtain Required FBI Background Check Prior to Hiring Staff
Penalty
Summary
The facility failed to thoroughly screen an individual prior to hire by not obtaining a required FBI criminal background check for one of five employee records reviewed (Employee E3). The facility’s Criminal Record/FBI Check Policy, revised March 14, 2022, required that a criminal record check and, when applicable, an FBI national check be processed for all staff members upon hire, specifying that an FBI check is required if the staff member is not a current Pennsylvania resident or has not been a state resident for the two years preceding the application. Review of Employee E3’s personnel record showed that this employee was hired on December 18, 2025, with no evidence that an FBI check had been initiated or completed. In an interview on February 20, 2026, at 12:43 p.m., the Nursing Home Administrator confirmed that Employee E3 had not been a Pennsylvania resident for the required two-year period and that the FBI check had not been completed, resulting in noncompliance with the facility’s policy and regulatory requirements related to screening for abuse, neglect, exploitation, or theft findings.
Failure to Document Medication Disposition at Discharge
Penalty
Summary
The facility failed to ensure accurate documentation of the disposition of medications upon discharge for one discharged resident. Facility policy on disposition of noncontrolled medications, revised in December 2025, required the licensed nurse to remove all of a discharged resident’s medications from the medication cart, count the remaining quantities, and document the disposition by printing the resident’s eMAR, recording the amounts of medications returned to the pharmacy on the printout, dating and initialing it, and scanning it into the EHR; alternatively, the nurse could document in an ID note the medication names, dosages, amounts remaining, and disposition. Clinical record review for Resident 51, who was discharged to independent living on December 19, 2025, showed that the nurse discharge summary stated all medications were given to the resident, but did not record or document the quantity of medications. In an interview on February 20, 2026 at 1300, the Director of Nursing confirmed that the required documentation of medication disposition was not completed for this resident, constituting noncompliance with 28 Pa. Code 211.5(d)(f) regarding clinical records.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to a resident's care plan, resulting in a fall and subsequent harm. Resident 52, who had a care plan for continence management, was not toileted according to the specified schedule. The care plan required checks and changes upon waking, before bed, before and after meals, and at specific times during the night. However, the resident was last toileted at 9:00 a.m., and the fall occurred later that morning. The resident was found on the floor with a large hematoma on the forehead, complaining of dizziness and an upset stomach, and was subsequently transported to the emergency room for evaluation. The facility's documentation and staff interviews revealed that Resident 52 had been repositioned in a Broda chair multiple times before the fall, indicating attempts to move forward in the chair. Despite these observations, the care plan was not followed, as the resident was not toileted as required. The post-fall investigation confirmed that the root cause of the fall was the failure to follow the toileting care plan, leading to the resident's fall and injury.
Plan Of Correction
In accordance with Facility Policy-Comprehensive Person-Centered Care Plan (#11.01), the Interdisciplinary Team will meet each resident's goals, based on a comprehensive assessment of the resident's physical, psychological, social and spiritual needs. In addition, in accordance with Facility Policy - Minimum Data Set (MDS) Completion (#11.02), residents residing in skilled nursing will be assessed by the Interdisciplinary Team upon admission, annually, quarterly and with significant change in condition. A review of Resident #52 indicated the facility completed assessments for reference periods 5-14-24 to 5-20-24 (Comprehensive Admission Assessment); 8-14-24 to 8-20-24 (Quarterly Assessment) and 11-13-24 to 11-29-24 (Quarterly Assessment). A comprehensive review of Resident #52 Care Plans was completed January 23, 2025 by the Interdisciplinary Team and found to be current. All resident care plans are reviewed annually, quarterly and with significant change in condition. In accordance with the Facility Policy 5.13 - Resident Info SNAP Sheet, the Facility will conduct an audit using the Care Plan Audit Form of all current resident Care Plans, covering Activities of Daily Living, Continence and Falls Prevention Care Plans to ensure Care Plans are current no later than March 7, 2025. Findings will be reported at the next quarterly Quality Assurance Committee meeting. Utilizing a Care Plan Monitoring Tool, beginning February 17th, 2025, a Facility staff member/designee shall monitor 10% of current residents weekly for the first four weeks to ensure care plans of current residents are being followed. Thereafter, monitoring of 10% of current residents will occur on a monthly basis up to 90 days. Findings will be reported at the next quarterly Quality Assurance Committee meeting. All staff will be educated on the definition, importance, and process for the comprehensive plan of care of residents no later than 2/21/2025.
Failure to Investigate Possible Abuse/Neglect Incident
Penalty
Summary
The facility failed to investigate an incident involving possible abuse or neglect of a resident. The incident involved a resident who fell from a Broda chair and sustained a large hematoma on the forehead, along with other symptoms such as dizziness and an upset stomach. The resident was sent to an acute care facility to rule out a head bleed, and upon return, was found to have bruising and fecal smearing. The facility's policy requires immediate reporting and investigation of suspected abuse or neglect, but this was not followed in this case. The resident's care plan included a specific toileting program, which was not adhered to, leading to the fall. The resident had been observed earlier attempting to move forward in the Broda chair and was repositioned by staff. Despite these observations and the fall, the facility did not conduct an investigation into potential abuse or neglect, as confirmed by an interview with a licensed employee. The failure to follow the care plan and the lack of investigation into the incident constitute the deficiency.
Plan Of Correction
The Facility will conduct a review of all current residents in similar situations for which an Electronic Event Report was submitted to the Pennsylvania Department of Health during the period January 9, 2024 to January 9, 2025. The Neglect Screening Tool will be utilized to conduct this review by the Interdisciplinary Team to ensure there were no other instances that required further investigation to determine neglect. Review will be completed no later than 2/28/25. Findings of this audit will be shared with the Facility Quality Assurance Committee at the next quarterly meeting. All staff will be re-educated on Facility Policy and Procedure titled Resident Abuse/Neglect/Misappropriation of Property Prevention (12/23) no later than 2/21/25. The training referenced above will also include discussion of the procedures to follow where, in different situations than this, "neglect" is found, and the subsequent investigations and reporting that must accompany such a finding. A follow-up review of incident and resident 52's medical record was conducted on January 20 -23, 2025 by Administrator, Director of Nursing, Medical Director and members of the Interdisciplinary Team. A Preventative Abuse Incident Monitor will be conducted by NHA or designee to include: Missing Property, Skin Incidents of Unknown Origin and Events Reported to Department of Health involving Abuse, Neglect, Misappropriation. This monitor will include any similar situations involving Event Reports submitted reported to the Pennsylvania Department of Health in which the checklist was utilized. Findings will be reported at the Quarterly QA Committee Meeting.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one of the 24 residents reviewed. Specifically, for Resident 58, the discharge Minimum Data Set (MDS) assessment inaccurately indicated that the resident was discharged to an acute hospital. However, a review of the clinical record, including the discharge/transfer summary dated December 5, 2024, revealed that the resident was actually discharged home on that date. This discrepancy was confirmed during an interview with the RNAC, Employee E4, on January 9, 2025, at 11:50 a.m., who acknowledged that the MDS assessment was marked incorrectly.
Plan Of Correction
Upon review of MDS assessment for Resident 58, discharge location was marked in error on Discharge MDS Assessment of Resident 58. Correction was immediately made ("hospital to home") and resubmitted on January 9, 2025, while the surveyor was onsite. RNAC will run "Discharge Register" from EMR on a monthly basis to conduct an audit of discharge MDS and death trackers to confirm accuracy of discharge location. Findings of the audit will be included in the monthly Quality Assurance Documentation Committee report and reported at the quarterly Quality Assurance Committee meeting.
Failure to Timely Notify Physicians of Medication Errors
Penalty
Summary
The facility failed to notify the physician in a timely manner of multiple medication errors experienced by 15 residents. The errors, which were due to inaccuracies from the contracted pharmacy, were identified through internal audits and investigations conducted by the facility. From September 1, 2023, through October 22, 2023, 15 residents experienced 70 medication errors. Despite these findings, the attending physicians were not informed of the errors until December 14 and 15, 2023. This delay in notification was confirmed by the Director of Nursing and the Nursing Home Administrator during interviews on January 22, 2024.
Failure to Address Pharmacy Delivery Errors
Penalty
Summary
The facility failed to identify and address pharmacy delivery errors, resulting in multiple medication errors for 15 residents. These errors were due to the pharmacy delivering medications late, which led to the residents not receiving their prescribed medications on time. The errors included missed doses of critical medications such as Gabapentin, Remeron, Combigan, Latanoprost, Travatan, Saline Nasal Spray, Cosopt, Restasis, Vitamin C, Oyster Shell, Vitamin D3, Vitamin B Complex, Melatonin, Guafenesin, Ferrous Sulfate, Clonazepam, Albuterol, Rytary, Famotidine, Beano, Allegra, Centrum, and Senna. These medications are used to treat various conditions, including pain, appetite stimulation, glaucoma, calcium deficiency, insomnia, iron deficiency, restless leg syndrome, asthma, Parkinson's, nausea, allergies, and constipation. The facility conducted internal audits and investigations, revealing that from September 1, 2023, through October 22, 2023, 15 residents experienced 70 medication errors due to late deliveries from the contracted pharmacy. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the frequency and impact of these errors. Specific instances included multiple missed doses for individual residents, such as R1 not receiving Gabapentin on September 20, 2023, and R2 missing doses of Remeron on three separate occasions. The facility's failure to ensure timely delivery of medications from the pharmacy led to significant medication errors, affecting the health and well-being of the residents. The DON and NHA acknowledged the issue and confirmed that the facility is in the process of finding a new pharmacy to meet the residents' needs. The facility also provided education to nursing staff on medication error policies and conducted pharmacy and medication audits in November and December 2023.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 889 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kennett Square
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pocopson Home | 1 mi | ★★★★★ | 0 | 0 |
| Kendal At Longwood | 3.3 mi | ★★★★★ | 0 | 0 |
| West Chester Rehabilitation And Healthcare Center | 4.7 mi | ★★★★★ | 2 | 0 |
| Barclay Friends | 6.3 mi | ★★★★★ | 0 | 0 |
| Continuing Care At Maris Grove | 6.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Crosslands.
100% money-back within 48 hours.
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.