Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Zerbe Sisters Nursing Center, during CMS and state inspections, most recent first.
A resident with a history of falls and mobility issues required two-person assistance for transfers. However, a single nurse aide attempted the transfer, resulting in the resident being lowered to the floor when their knees buckled. The facility's investigation confirmed the deviation from the care plan, as the aide did not wait for additional assistance and did not use a gait belt.
The facility failed to document medication disposition for two discharged residents, violating its policy on pharmaceutical services. One resident expired while hospitalized, and no medication disposition form was found. Another resident was discharged home, but the medication list lacked the quantity of medications dispensed. The DON confirmed these documentation issues.
The facility failed to maintain the smoke resistance of smoke barrier walls, as an unprotected penetration was found above the East Hall smoke barrier cross-corridor doors. This issue was confirmed by the Maintenance Manager during an interview.
The facility failed to document the inspection of diesel fuel quality for the emergency generator within the past year, as required by NFPA standards. The last recorded inspection was over a year ago, and the Maintenance Manager confirmed the absence of recent documentation.
The facility was found to have exceeded the maximum allowable story height for a Type III (200), unprotected ordinary structure. This was observed during a survey, and the Maintenance Manager confirmed the building's construction type exceeded the permitted number of stories for health care facilities.
The facility failed to comply with NFPA 101 requirements by not providing at least two remote exits for two of its smoke compartments. Observations revealed that the 2nd floor Annex and the basement lacked the necessary exits. This was confirmed by the Maintenance Manager.
The facility did not have documentation verifying that the Kitchen Fire Suppression System was inspected semi-annually within the past year. An interview with the Maintenance Manager confirmed the absence of inspection records since March 2024.
Inadequate Supervision During Toileting Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision during a toileting transfer for Resident 55, resulting in a fall. Resident 55, who has a history of repeated falls, generalized weakness, and impaired mobility, required extensive two-person assistance for transferring and toileting as per their care plan. On the day of the incident, the resident was being transferred from the toilet to a wheelchair by a single nurse aide, despite the care plan specifying the need for two-person assistance. During the transfer, the resident's knees buckled, and the aide lowered the resident to the floor. The facility's investigation revealed that the nurse aide, Employee E3, did not wait for a second person to assist with the transfer, as instructed by Employee E4, who was responsible for orientation. Additionally, a gait belt was not used during the transfer, which was a deviation from the standard procedure. The Director of Nursing confirmed that the resident required two-person assistance, and the failure to provide this level of care resulted in the resident being lowered to the floor during the transfer.
Failure to Document Medication Disposition for Discharged Residents
Penalty
Summary
The facility failed to document medication disposition for two discharged residents, leading to a deficiency in pharmaceutical services. According to the facility's policy, the disposal of controlled substances must occur immediately, or within three days, after discontinuation of use by a resident. This disposal must be documented on a medication disposition record with the signatures of at least two witnesses. However, for Resident 76, who expired while hospitalized, there was no medication disposition form found in the clinical records. Resident 76 had been transferred to the hospital due to a change in mental status and shortness of breath and was admitted with congestive heart failure exacerbation. For Resident 7, who was discharged to home, the clinical records included a medication list but failed to document the quantity of each medication dispensed. The discharge summary indicated that medication reconciliation was completed, but the medication disposition sheet did not include the necessary details. An interview with the Director of Nursing confirmed the absence of a medication disposition sheet for Resident 76 and the incomplete documentation for Resident 7.
Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring safety in the event of a fire. During an observation, it was found that there was an unprotected penetration in the smoke barrier wall located above the suspended ceiling, specifically above the East Hall smoke barrier cross-corridor doors. This penetration was around gray wires, compromising the integrity of the smoke barrier. The Maintenance Manager confirmed the presence of this unprotected penetration during an interview.
Plan Of Correction
The facility will maintain the rating of the smoke barrier walls. The identified penetration of the smoke barrier wall has been sealed using an approved through penetration fire stop system in order to maintain the rating of the smoke barrier. Other areas within the component shall be rechecked for penetrations and, if found, sealed with approved through penetration fire stop system in order to maintain the rating of the smoke barriers. Ongoing monitoring of penetrations have been added to the electronic task work order system, and shall be overseen by the director of maintenance/designee. Director of Maintenance shall report on any ongoing findings of penetrations and sealing performed to the QAPI committee for review/recommendation for a period of three months. Maintenance staff shall be educated by Administrator on the NFPA 101 Standard for maintaining smoke barrier walls.
Failure to Document Diesel Fuel Quality Inspection for Emergency Generator
Penalty
Summary
The facility failed to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been inspected within the previous twelve months. This deficiency was identified during a document review conducted on February 11, 2025, at 10:30 AM. The review revealed that the last documented inspection of the diesel fuel quality was dated February 8, 2023, indicating a lapse in the required annual inspection schedule. An interview with the Maintenance Manager on the same day confirmed the absence of documentation verifying the inspection of the diesel fuel quality within the past year. This lack of documentation suggests that the facility did not adhere to the necessary maintenance and testing protocols for the emergency generator's fuel supply, as required by the relevant NFPA standards.
Plan Of Correction
Contractor has been contacted to schedule testing of the emergency generator fuel. Testing frequency has been added to the electronic work order system to ensure notification of future scheduling with the contractor. Administrator and Maintenance Director shall review upcoming required tests in the electronic task work order system during monthly meeting, to ensure proper scheduling is completed in future. The Maintenance Director shall be responsible for assuring the completed testing documentation is filed in the Life Safety book for future reference. Scheduling of and completion for required contractor tests and inspections shall be reported by Director of Maintenance to QAPI committee for review/recommendation for three months. Maintenance department has been educated by Administrator on the requirement for testing the diesel fuel for the emergency generator.
Building Construction Type Exceeds Allowable Height
Penalty
Summary
The facility failed to maintain building construction requirements, specifically exceeding the maximum allowable story height for a Type III (200), unprotected ordinary structure. This deficiency was identified during an observation on February 11, 2025, at 12:30 PM, which revealed that the building's construction type exceeded the number of stories permitted for health care facilities. The Maintenance Manager confirmed this finding during an interview conducted at the same time, indicating a lapse in adhering to the established building construction standards for the facility.
Non-Compliance with NFPA 101 Exit Requirements
Penalty
Summary
The facility was found to be non-compliant with the NFPA 101 requirement for providing at least two exits, remote from each other, for each story and smoke compartment. During an observation conducted on February 11, 2025, between 11:30 AM and 1:30 PM, it was noted that two of the seven smoke compartments within the component lacked the required exits. Specifically, the 2nd floor Annex and the basement did not have two exits that were remote from each other. This deficiency was confirmed through an interview with the Maintenance Manager at 1:30 PM on the same day.
Lack of Documentation for Kitchen Fire Suppression System Inspection
Penalty
Summary
The facility failed to provide documentation verifying that the commercial Kitchen Fire Suppression System had been inspected on a semi-annual basis within the previous twelve months. During a document review on February 11, 2025, it was discovered that there was no documentation available to confirm that the Kitchen Fire Suppression System had been inspected since March 6, 2024. This deficiency was confirmed during an interview with the Maintenance Manager, who acknowledged the lack of documentation for the required inspection of the Kitchen Suppression System.
Plan Of Correction
Inspection of the Kitchen Suppression System has been scheduled with the contractor. Inspection of the Kitchen Suppression System shall be added to the electronic task work order system by the Maintenance Director to alert when to schedule each regulatory required inspection based upon its frequency requirement. The Maintenance Director/designee shall monitor, maintain and update the electronic task work order system weekly for upcoming and completed regulatory required inspections. Administrator and Maintenance Director shall review upcoming required tests and inspections in the task work order system during monthly meeting, to ensure proper scheduling. The Maintenance Director shall be responsible for assuring the completed inspection documentation is properly filed in the Life Safety book. Administrator shall educate the maintenance department regarding semi-annual inspection requirement of the Kitchen Suppression System.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory House Nursing Home | 7.7 mi | ★★★★★ | 10 | 0 |
| Tel Hai Retirement Community | 8.1 mi | ★★★★★ | 2 | 0 |
| Garden Spot Village | 8.2 mi | ★★★★★ | 2 | 0 |
| Mifflin Center | 9.1 mi | ★★★★★ | 7 | 0 |
| Highlands At Wyomissing | 10.5 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.