Above average — CMS composite of the measures below.
The next survey window likely opens 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 Sarah Reed Senior Living during CMS and state inspections, most recent first.
A resident with a history of stroke, heart failure, and kidney failure was not weighed according to physician orders, which required daily weights during the first ten days of each month. Facility records showed no documentation of weights since admission, and the DON confirmed this omission.
The facility did not maintain proper electrical system protection in the ground floor laundry room. Electrical outlets were found within six feet of washing machines without GFCI receptacles, as confirmed by the maintenance supervisor.
The facility did not maintain building construction standards in the accounting office storage room, where two ceiling tiles were missing. This issue could potentially allow smoke passage and delay sprinkler activation. The maintenance supervisor confirmed the tiles were missing during the survey.
A facility failed to provide written summaries of baseline care plans and order summaries to three residents or their representatives within 48 hours of admission, as required by policy. The residents, with various medical conditions including heart failure, dementia, and hypertension, did not receive documentation of their care plans, medications, and treatments. The Nursing Home Administrator confirmed the absence of these documents in the clinical records.
A facility failed to ensure a resident with limited ROM received physician-ordered treatment to prevent further decline. The resident, diagnosed with dementia and osteoarthritis, had a physician's order for a left palm protector to be worn at all times except during hygiene. Observations revealed the resident was not wearing the protector, and staff confirmed it should have been worn daily. Clinical records lacked evidence of intolerance, indicating a deficiency in care.
The facility failed to document the required 14-day stop dates or provide clinical rationales for the continued use of PRN Lorazepam for two residents. One resident with heart failure and anxiety and another with dementia and anxiety had orders for Lorazepam that did not comply with the facility's policy, as confirmed by the Nursing Home Administrator.
A facility failed to manage medications properly, as evidenced by expired Humalog insulin and improperly labeled Lantus insulin in a medication cart. The Humalog insulin exceeded the 28-day discard period, and the Lantus insulin lacked an open date, preventing staff from determining its expiration. A nurse confirmed these oversights during an interview.
The facility did not adhere to food safety standards, as observed in the kitchen's walk-in cooler and dry storage area. Expired items, including pasta salad, pureed ham, molasses, and baking soda, were found and confirmed by the Dietary Manager to be past their use-by dates, contrary to facility policy.
The facility failed to store food in accordance with safety standards in the walk-in freezer. During a kitchen tour, several food items were found on the floor, contrary to the facility's policy. The Food Service Director confirmed the improper storage.
The facility failed to complete discharge summaries for three residents, missing essential elements such as a recapitulation of the stay, final summary of status, and cause of death. The DON confirmed these deficiencies during interviews.
The facility failed to ensure that the pharmacist provided separate, written reports of irregularities identified during the medication regimen review for a resident with multiple diagnoses, including left-sided paralysis post-stroke and dementia. The clinical record lacked evidence that findings were communicated to the DON and medical director, as required by facility policy.
The facility failed to provide a clinical rationale and duration for the continued use of PRN psychotropic medication beyond 14 days for two residents. Orders for Lorazepam and Haloperidol lacked the required stop date or clinical rationale, and one resident was not evaluated by the attending physician for the continuation of an anti-psychotic medication.
Failure to Obtain Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain weights for a resident according to physician's orders. Facility policy required all residents to be weighed by the 10th of each month, and a physician's order specified that the resident was to be weighed every day shift from the 1st to the 10th of each month. Review of the clinical record showed that, since admission, there was no documentation that the resident had been weighed as ordered. The Director of Nursing confirmed during an interview that the resident had not been weighed since admission. The resident had diagnoses including stroke, heart failure, and kidney failure.
Electrical System Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain electrical system protection in wet locations, specifically on the ground floor laundry room. During an observation, it was noted that electrical outlets were located within six feet of the washing machines and were not equipped with ground fault circuit interrupter (GFCI) receptacles. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the receptacle deficiencies.
Plan Of Correction
1. All three identified outlets in the ground floor laundry room will be replaced with the proper GFCI outlets. 2. All other outlets in the ground floor laundry room will be audited to ensure no other outlets need to be changed to GFCI's, if within 6 feet of a sink. 3. Outlets will be monitored and reported at the next quarterly QAPI meeting/Safety meeting by Director of Maintenance.
Deficiency in Building Construction Maintenance
Penalty
Summary
The facility failed to maintain the building construction standards as required, specifically in the ground floor accounting office storage room. During an observation, it was noted that two ceiling tiles were missing, which could potentially allow the passage of smoke and delay the activation of the sprinkler system. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged that the ceiling tiles were missing at the time of the survey.
Plan Of Correction
1. The two ceiling tiles in the ground floor accounting office were immediately replaced at time of discovery on 12/17/2024. 2. All other ground floor storage rooms will be audited to ensure no other ceiling tiles are missing. 3. Education to be completed with maintenance team on the importance of ceiling tile placement. 4. Ceiling tiles will be monitored and reported at the next quarterly QAPI/Safety meeting by the Director of Maintenance.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to three residents or their representatives within 48 hours of admission, as required by their policy. The policy, dated 2/15/24, mandates that a copy of the baseline care plan be given at the new admission care plan meeting, typically held within 48 hours of admission. This includes a summary of the resident's medications, dietary instructions, and any services and treatments to be administered. However, the clinical records for three residents lacked evidence of this documentation. Resident R8, admitted with diagnoses including heart failure, atrial fibrillation, and anxiety, did not receive the required documentation. Similarly, Resident R15, with dementia, osteoarthritis, and hypothyroidism, and Resident R60, with hypertension, hypothyroidism, and congestive heart failure, also did not receive the necessary written summaries. The Nursing Home Administrator confirmed the absence of these documents in the clinical records during an interview, indicating a failure to comply with the facility's care plan policy.
Plan Of Correction
1) Baseline Care Plan to be provided to R60, R15, and R8 with completion of Admission Care Plan assessment in PointClick Care. 2) Admission Care Plan assessment created in PointClick Care for nursing staff to complete at time of admission with proof that baseline care plan was provided. 3) Provide training to LPN's/RNs on new assessment and importance of completing the required documentation. 4) The Director of Nursing/designee will audit all new admissions/recent admissions for completion of assessment; 1x weekly for 3 weeks then 1x monthly x2. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Failure to Provide Physician-Ordered Range of Motion Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the physician-ordered treatment and services necessary to prevent further decline in range of motion. Specifically, Resident R15, who was diagnosed with dementia, osteoarthritis, and hypothyroidism, had a physician's order for a left palm protector to be worn at all times except during hygiene activities. However, multiple observations over several days revealed that the resident was not wearing the palm protector as prescribed. The clinical records lacked documentation indicating that the resident was unable to tolerate the palm protector, and staff interviews confirmed that the resident should have been wearing it daily according to the physician's orders. Despite education provided to staff upon the resident's discharge from occupational therapy, the facility did not ensure compliance with the prescribed use of the palm protector, leading to a deficiency in the care provided to Resident R15.
Plan Of Correction
1) R15 to be assessed by therapy to ensure that the resident is receiving the appropriate interventions and therapies. R15 physician order to be changed to specify correct adaptive equipment. 2) Complete facility wide assessment to identify other residents with palm protectors to ensure proper documentation/orders. 3) Provide training to LPNs/CNAS on the importance of palm protectors and documentation of refusals. 4) Restorative Nurse/designee will audit all residents with adaptive equipment with hand contractures for appropriate use and documentation; 1x weekly for 3 weeks then 1x monthly x2. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Failure to Document Required Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically Lorazepam, for two residents. The policy mandates that orders for psychotropic drugs are limited to 14 days unless a clinical rationale for continued use is documented. For Resident R8, who has diagnoses including heart failure, atrial fibrillation, and anxiety, a physician's order dated 11/12/24 prescribed Lorazepam 0.25 ml by mouth every 2 hours as needed for anxiety. This order did not include the required stop date within 14 days or a documented clinical rationale for its continuation beyond this period. Similarly, Resident R15, diagnosed with dementia, osteoarthritis, and hypothyroidism, had a physician's order dated 11/15/24 for Lorazepam 0.25 mg by mouth every 12 hours as needed for anxiety. This order also lacked the necessary 14-day stop date or a clinical rationale for continued use beyond 14 days. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging the absence of the required documentation for both residents.
Plan Of Correction
1) R15 and R8 stop dates to be added to Lorazepam. 2) All PRN psychotropic medications will be audited to ensure there is a stop date in place or documentation with rationale to continue the medication. 3) The nurses will be trained by the Director of Nursing/designee on ensuring there is a stop date in place for all PRN psychotropic medications unless there is documentation with rationale to continue the medication. 4) The Director of Nursing/designee will audit all new orders to ensure there are stop dates for all residents on PRN psychotropic medications and rationale to support continued use; 1x weekly for 3 weeks then 1x monthly x2. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Expired and Improperly Labeled Insulin Found in Medication Cart
Penalty
Summary
The facility failed to ensure proper medication management as evidenced by the presence of expired and improperly labeled insulin in one of the medication carts. During a review of the facility's policy on medication storage, it was noted that medications and biologicals should be stored safely and securely, following the manufacturer's recommendations. Specifically, insulin vials are to be stored in the refrigerator until opened, then dated and placed in the medication cart. However, during an observation of the [NAME] medication cart, a Humalog insulin vial was found with an opened date that exceeded the 28-day discard period recommended by the manufacturer. Additionally, a Lantus insulin vial was found without an open date, making it impossible to determine its discard date. During an interview, Registered Nurse Employee E2 confirmed the oversight, acknowledging that the Humalog insulin was expired and should have been discarded, and that the Lantus insulin lacked an open date, preventing staff from determining its expiration. This deficiency was identified during a survey, which included a review of facility policy, manufacturer's recommendations, observations, and staff interviews. The failure to adhere to proper medication labeling and storage protocols resulted in a violation of the facility's policy and state regulations regarding pharmacy and nursing services.
Plan Of Correction
1) 12/09/2024: Expired and undated insulin discarded from medication cart at the time of discovery. 2) All other medication carts were audited for expired/undated insulin the day the expired insulin was discovered. 3) FT/PT LPN's and RN's to be educated on proper med storage. 4) Medication carts will be audited on each unit for expired meds 1x weekly for 3 weeks then 1x monthly x2 by Director of Nursing. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage in accordance with food safety standards in one of two walk-in coolers and the dry storage area in the kitchen. During an inspection, it was observed that an open, partially used container of pasta salad was stored in the cooler with a use-by date that had passed. Additionally, the dry storage area contained eight cans of pureed ham with an expiration date of March 2024, an open gallon jug of molasses with a use-by date of October 2023, and two tubs of baking soda with an expiration date of May 2024. The Dietary Manager confirmed during an interview that these items were beyond their use-by or expiration dates and should have been discarded according to the facility's policy. The policies reviewed indicated that products past their use-by dates should be disposed of properly, and unconsumed food should be discarded in line with manufacturing guidelines and food labels.
Improper Food Storage in Walk-In Freezer
Penalty
Summary
The facility failed to ensure that food was stored in accordance with standards for food safety and sanitation in the walk-in freezer located in the main kitchen. During an initial kitchen tour, several food items were observed on the floor of the walk-in freezer. The facility policy, dated 2/6/2024, clearly indicated that all food items should be placed on shelves and not on the floor of the refrigerator or freezer. This observation was confirmed by an interview with the Food Service Director, who acknowledged that the food items should not be on the floor in the walk-in freezer.
Incomplete Discharge Summaries for Three Residents
Penalty
Summary
The facility failed to ensure that a discharge summary, which included a recapitulation of the resident's stay and the resident's discharge status, physician's final diagnosis and prognosis or cause of death, was completed for three closed clinical records. The facility's policies required an interdisciplinary discharge summary to be completed for all discharges, including a short summary of the resident's stay, final summary of resident status, disposition of medications, and physician's discharge prognosis, diagnosis, and cause of death. However, the clinical records for Residents CR94, CR95, and CR96 lacked these required elements. Resident CR94's record did not include a discharge summary with a recapitulation of the resident's stay and a final summary of the resident's status. Resident CR96's record was missing the physician's discharge summary, including the cause of death. Resident CR95's record lacked a recapitulation of the stay and the reason for discharge. The Director of Nursing confirmed these deficiencies during interviews, acknowledging the incomplete documentation in the residents' closed clinical records.
Failure to Document Pharmacist's Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the contracted pharmacist provided separate, written reports of irregularities identified during the medication regimen review (MRR) for one of five residents reviewed for unnecessary medications. The facility policy required that findings and recommendations from the MRR be communicated to the Director of Nursing (DON) or designee and the medical director, and documented in the resident's chart. However, for Resident R49, who had diagnoses including left-sided paralysis post-stroke, Type 2 Diabetes, heart failure, irregular heartbeat, and dementia, the clinical record lacked evidence that the pharmacist's findings and recommendations were communicated and documented as required. The DON confirmed the absence of such documentation during an interview.
Failure to Provide Clinical Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of PRN psychotropic medication beyond 14 days for two residents. Resident R34 had a physician's order for Lorazepam 0.5 mg every 24 hours PRN for anxiety, which lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Similarly, Resident R50 had a physician's order for Lorazepam 0.5 mg every four hours PRN for anxiety and Haloperidol 0.5 mg every four hours PRN for agitation, both of which lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Additionally, there was no evidence that Resident R50 was evaluated by the attending physician or prescribing practitioner for the continuation of the anti-psychotic medication Haloperidol. During an interview, the Nursing Home Administrator and Employee E1 confirmed that the orders for both residents lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. They also confirmed that Resident R50 was not evaluated by the attending physician or prescribing practitioner for the continuation of the anti-psychotic medication. This failure to comply with the facility's policy on psychotropic medications and regulatory requirements led to the identified deficiencies.
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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) |
|---|---|---|---|---|
| Lecom At Village Square, Llc | 0.1 mi | ★★★★★ | 3 | 0 |
| Nightingale Nursing And Rehab Center | 1 mi | ★★★★★ | 9 | 0 |
| Lecom At Elmwood Gardens, Llc | 1.3 mi | ★★★★★ | 1 | 0 |
| Pennsylvania Soldiers And Sailors Home | 1.6 mi | ★★★★★ | 9 | 0 |
| Greenfield Healthcare And Rehabilitation Center | 2.6 mi | ★★★★★ | 25 | 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.