Citations in Pennsylvania
Statistics, citations and compliance trends for long-term care facilities in Pennsylvania.
Statistics for Pennsylvania (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Pennsylvania
Food Items Left Unlabeled and Undated: The facility failed to properly label and date food products in the main kitchen's standing cooler rack and dry storage area. A Dietary Supervisor confirmed that three chef's salads, seven sandwiches, and an opened container of chicken gravy/bouillon were not labeled or dated, even though the salads were from the prior evening's dinner meal and should have been labeled and dated.
Food items were found stored beyond their use dates in the main kitchen and two kitchenette refrigerators. Surveyors observed expired dry goods, prepared foods, dairy items, lunch meat, horseradish, and an opened med pass supplement, and the Dietary Manager, an LPN, and an RN confirmed the items should have been discarded.
Failure to maintain resident dignity was identified when three residents with indwelling urinary catheters had drainage bags hanging on the bedframe without privacy covers, despite physician orders for privacy covers every shift. In addition, a resident who was ordered to be fed by staff was observed being fed by a nurse aide standing beside the bed during lunch, and the DON confirmed the dining experience was not dignified.
Failure to Hold and Notify Residents of Care Plan Conferences: The facility did not conduct required care plan conferences or ensure advance notification to the resident or resident representative for three residents. One resident with DM, HTN, and CAD, one resident with HTN, HF, and DM, and one resident with insomnia, anxiety, and ALS all had missing quarterly care conferences, and one resident stated he had only attended one conference since admission and had not been invited to others.
The facility failed to document that necessary resident information was sent with three hospital transfers, including care plan goals, advance directive information, ongoing care instructions, and resident representative information. It also failed to notify two residents or their representatives of the bed-hold policy and failed to notify the State LTC Ombudsman for three hospital transfers. The DON and Regional Director of Clinical Services confirmed the missing documentation and notifications.
Failure to Follow Ordered Treatments and Weight Monitoring: The facility did not ensure ordered care was carried out for several residents. One resident with Parkinson’s disease and anxiety sustained a skin tear to the hand during an agitated episode, but there was no physician order for the wound treatment that was provided. Two residents had ordered weekly weights that were not obtained as scheduled, and the records did not explain why. Another resident with HTN, depression, and DM had body blisters, but the wound company’s recommendation for skin prep was not entered as an order, and there was no documented evidence that the practitioner was contacted about the missed recommendation.
Food Items Left Unlabeled and Undated
Penalty
Summary
The facility failed to properly label and date food products in the main kitchen's standing cooler rack and dry storage area. Review of the facility's Food Preparation and Handling Policy dated 5/4/26 indicated that potentially hazardous foods are to be kept refrigerated except when being handled, and refrigerated foods are to be covered for storage, cooked timely following defrosting, and appropriately labeled and dated. During observation in the Main Kitchen on 8/3/26 at 9:20 a.m., a tray in the standing cooler rack contained three separate chef's salads and seven sandwiches that were not labeled and dated. In the dry storage area, a container of chicken gravy/bouillon was found opened and not labeled or dated. During interview on 8/3/26 at 9:30 a.m., the Dietary Supervisor confirmed the salads were from the prior evening's dinner meal and stated they, along with the sandwiches, should have been labeled and dated; the Dietary Supervisor also confirmed the chicken gravy/bouillon should have been labeled and dated.
Food Items Stored Beyond Use Dates
Penalty
Summary
Food was not stored in accordance with food safety standards in the main kitchen and in two kitchenettes. During a tour of the main kitchen, surveyors observed a bag of Oreo cookie crumbles in dry storage with a best buy date of 5/11/26, three metal pans in the first walk-in refrigerator containing prepared peas dated 7/30/26, prepared mixed vegetables dated 7/31/26, and prepared chicken dated 7/29/26, and three cartons of whip cream in the second walk-in refrigerator with best buy dates of 7/31/26, an opened package of corned beef lunch meat dated open 7/21/26, and an opened container of horseradish with a best by date of 7/6/26. The Dietary Manager confirmed these items were beyond their use by dates and should have been discarded. In the 100-hall kitchenette refrigerator, surveyors observed an opened container of med pass supplement with an open date of 7/18/26, and an LPN confirmed it was beyond its use by date and should have been discarded. In the 400-hall kitchenette refrigerator, surveyors observed an opened half gallon of lactose free milk with a best buy date of 8/1/26 and a half gallon of regular milk with a best buy date of 8/4/26, and an RN confirmed both were beyond their use by dates and should have been discarded.
Failure to Maintain Resident Dignity During Catheter Care and Dining
Penalty
Summary
The facility failed to maintain resident dignity by not ensuring privacy covers were applied to urinary catheter drainage bags for three residents. Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a physician order for catheter care to provide a privacy cover for the drainage bag every shift. During observation, the catheter drainage bag was hanging on the bedframe without a privacy cover. Resident R178, with diagnoses of diabetes, high blood pressure, and depression, also had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. Resident R179, diagnosed with COPD, atrial fibrillation, and heart failure, likewise had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. An RN confirmed that the bags should be covered and that the residents' dignity was not maintained. The facility also failed to provide a dignified dining experience for one resident who was ordered to be fed by staff. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had a care plan and physician order for staff to feed all meals. During lunch observation on the 2B nursing unit, the resident was sitting upright in bed while a nurse aide stood beside the bed feeding the resident. The nurse aide stated that they should have been sitting down while feeding but did not know where the resident's chair was. The DON later confirmed that the facility failed to provide the right to a dignified dining experience for one of two lunches observed on 2B.
Failure to Hold and Notify Residents of Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences and failed to ensure that residents or their resident representatives were notified in advance of care conference meetings for three residents. Review of the facility policy showed that an interdisciplinary plan of care was to be established and updated as indicated for every resident, with resident or representative participation included unless participation was not practicable and documented in the medical record. However, review of care plan conference records showed that Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a last documented care conference on 1/29/26 and no documented quarterly care conferences in April 2026 or July 2026. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had an admission care conference on 10/1/25 with no attendee list except the staff member and no documented quarterly care conferences in January 2026 or May 2026. Resident R91, who had diagnoses of insomnia, anxiety, and ALS, stated during interview that he had only been to one care conference since admission and had not been invited to any others; records showed an admission care conference on 6/4/25 and no documented quarterly care conferences in September 2025, December 2025, March 2026, or June 2026. The Social Worker Aide confirmed the missing quarterly care conferences for all three residents, and the Nursing Home Administrator confirmed the facility failed to conduct care plan conferences and failed to ensure advance notification to the resident or resident representative.
Failure to Communicate Transfer Information and Notify of Bed-Hold and Ombudsman
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers. For Residents R4, R10, and R72, the clinical record did not show documentation that the facility sent specific information to the acute hospital, including care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and other information needed to meet the resident’s specific needs at the receiving facility. Staff interviews confirmed that the resident information sent with these transfers was not documented. The facility also failed to notify the resident or the resident’s representative of the bed-hold policy for two hospital transfers, Residents R4 and R10, and failed to notify the Office of the State Long-Term Care Ombudsman for three hospital transfers, Residents R4, R10, and R72. Resident R4 had diagnoses including diabetes, depression, and multiple sclerosis and was transferred to the hospital and later returned to the facility. Resident R10 had diagnoses including diabetes, cerebral infarction, and depression and was also transferred to the hospital and returned. Resident R72 had diagnoses including high blood pressure, chronic pain, and COPD and was transferred to the hospital and returned the same day. The DON and Regional Director of Clinical Services confirmed the missing documentation and the lack of Ombudsman notification.
Failure to Follow Ordered Treatments and Weight Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with orders and professional standards for four residents. Facility policy stated that weights were to be obtained routinely to monitor nutritional health, including weekly for the first four weeks after admission or readmission and more often if risk was identified or as ordered. For one resident with diagnoses including high blood pressure, Parkinson’s disease, and anxiety, a nursing note documented that the resident sustained a skin tear to the right hand during an episode of agitation and attempted physical aggression toward staff while being assisted out of bed. The wound nurse confirmed there was no physician order for treatment of the right hand skin tear, although steri-strips had been applied and the wound nurse stated steri-strips are the preferred treatment for skin tears. For two residents, physician orders required weekly weights, but the clinical record did not show that the ordered weights were obtained as directed. One resident had weights not obtained on two scheduled dates, and the record lacked additional documentation explaining why the weights could not be obtained. Another resident had one missed weekly weight, and the record also lacked additional documentation explaining why the weight was not obtained. The DON confirmed that the facility failed to make certain these residents were provided appropriate treatment and care. For another resident with diagnoses including hypertension, depression, and diabetes, the record showed the resident was admitted with marks and blisters on the body and no treatment was ordered. A contracted wound company later recommended skin prep to the blisters, but physician orders did not include skin prep. A wound nurse stated there was no order for skin prep and confirmed the facility did not follow the wound company’s recommendations. An RN stated the recommendations were not followed, but the facility had no documented evidence of speaking with the practitioner about treatment for the blisters or the reason the recommendations were not followed.
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Compliance trends in Pennsylvania
Data through Jul 2026Comparisons below measure the most recent period Aug 2025 – Jul 2026 against the prior period Aug 2024 – Jul 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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