No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Centre Care Rehabilitation And Wellness Services

250 Persia Road, Bellefonte, PA 16823 · Non profit - Corporation · 240 certified beds · (814) 278-6000 Medicare & Medicaid certified

Call the home — (814) 278-6000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0610) — most recent Aug 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2581 Clyde Avenue
Pharmacy
1300 Benner Pike · (814) 867-1970 · Call to confirm hours
Grocery
Aldi0.7 mi
780 Benner Pike · (855) 955-2534 · Call to confirm hours
Park
2601 Penbrook Ln · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.2%16.8%15.4%worse
Long-stay residents who lose too much weight4.2%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.1%0.7%0.9%better
Long-stay residents with a urinary tract infection2.8%1.5%2.0%worse
Long-stay residents with depressive symptoms1.8%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.2%3.1%3.3%worse
Long-stay residents whose ability to walk worsened19.1%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.0%20.0%18.9%typical
Long-stay residents given the seasonal flu vaccine97.7%93.5%95.3%typical
Long-stay residents with pressure ulcers5.3%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control21.1%25.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table19.8%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.5%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine92.4%68.7%79.4%better
Short-stay residents rehospitalized after admission24.2%22.5%22.6%typical
Short-stay residents with an outpatient ER visit3.3%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.151.621.67better
Long-stay outpatient ER visits per 1,000 resident days0.391.181.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

34.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

34.2%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
45.5%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 45.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 55 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF34.2%CMS range 26.9–41.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 8.1–14.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge45.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge30.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.2%CMS range 2.8–9.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.641.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.46
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.04
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.19
RN hoursweekends
36.3%
Total nursing turnover
13.0%
RN turnover

How full it usually is: this home is certified for 240 beds and averages 223.6 residents a day — about 93% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.02 hrs/resident/day on weekends vs 3.61 on weekdays — 16% thinner on weekends. RN hours go from 0.57 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2025-08-15)
10
at the previous standard inspection (2024-10-08)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · E2025-08-15 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to obtain informed consent for use of side rails/enabler bars for two of three residents reviewed (Residents 40 and 176); and failed to assess the entrapment risk associated with the use of side rails/enabler bars for two of three residents reviewed (Residents 40 and 149). Findings include: Clinical record review for Resident 40 revealed a diagnosis list that included weakness, generalized muscle weakness, and difficulty in walking. Observation of Resident 40 on August 12, 2025, at 11:19 AM revealed the resident was in bed. There was a side rail attached to the resident's right side of the bed. A concurrent interview with Resident 40 revealed the resident utilizes the side rail to help get around. Clinical record review for Resident 40 revealed no evidence that the facility obtained informed consent or assessed the side rail for entrapment risks. An interview with the Nursing Home…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure a complete and thorough investigation of an injury of unknown origin for one of one resident reviewed. (Resident 152) Findings include:Clinical record review for Resident 152 revealed a progress note dated June 27, 2025, that indicated staff observed a 5 centimeter (cm) by 4 cm purple bruise to the top of Resident 152's right breast. The progress note indicated that Resident 152 was known to transfer self from chair to bed and toilet and that she was also known to wander with poor safety awareness. Review of the facility's investigation report dated June 27, 2025, at 8:00 AM revealed that Resident 152 was observed with a 5cm x 4cm purple bruise to the top of her right breast. The report also indicated that Resident 152 was unable to give a description of what occurred. The report indicated that the immediate action taken was to assess and measure the area. The report also indicated that Resident 152 was known to transfer self from chair to bed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-15 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 35 residents reviewed (Resident 13). Findings include: Clinical record review of Resident 13's current physician orders revealed an order for Nuplazid (an antipsychotic medication used to treat hallucinations associated with Parkinson's disease) oral cap 34 mg (milligrams) po (by mouth) at bedtime that was ordered November 13, 2021. Review of Resident 13's clinical record revealed quarterly Minimum Data Set Assessments (MDS, a form completed at specific intervals to determine care needs) dated March 11, 2025, and June 10, 2025, that failed to indicate Resident 13 was taking an antipsychotic medication. Interview with the Director of Nursing and Nursing Home Administrator on August 14, 2025, at 1:45 PM confirmed the above noted information that the facility failed to accurately code Resident 13's MDS assessments dated March 11, 2025, and June 10, 2025. 483.20(g) Accuracy of AssessmentsPreviously cited 10/8/2024…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure the highest practicable care for a change in condition for one of 35 residents reviewed (Resident 228).Findings include: In an interview with Resident 228 on August 12, 2025, at 12:10 PM the resident indicated although she was primarily independent with activities of daily living (walking, dressing, toileting, hygiene), she has been declining over the past several months with worsening recently due to having pneumonia (lung infection) and a recent appendectomy (procedure to remove an appendix). Resident 228 indicated she felt since staff knew she was independent in the past they don't offer more help, and it has all been harder for her lately. A family member of Resident 228's indicated they were purchasing an electronic scooter for the resident so she could get around easier. Resident 228 stated she was not receiving therapy nor has therapy assessed her with her recent decline. The family member indicated the purchase of a scooter was the family's decision and did…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide timely assessments and implement interventions to promote acceptable parameters of nutritional status for one of seven residents reviewed for nutritional concerns (Resident 7). Findings include: The facility policy entitled Weighing of Residents, last reviewed without changes June 1, 2025, revealed the facility will monitor the resident's weight to detect significant weight loss or gain in order to ensure that the resident maintains acceptable parameters of nutritional status, taking into account the resident's clinical condition or other appropriate interventions, when there is a nutritional problem. If a resident exhibits a weight change of five pounds from the previous weight in a monthly report, the resident will be reweighed within 24 hours and the reweight will be recorded. If the weight is validated as a new greater than five percent change in one month, the resident will be reviewed by the registered dietitian to investigate the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on October 5, 2024, between 9:35 AM and 10:40 AM revealed the following: The walk-in freezer had multiple discarded items on the floor including under the storage shelves. These discarded items included the following: pieces of food (including broccoli and a piece of carrot), various paper products, and a balled-up hair net. Further observation of the walk-in freezer revealed four packages containing gluten free rolls with an expired use by date of 4/30. One of the packages was open to air exposing the rolls to the ambient air. A prep area in front of the freezer contained a drawer with various cooking utensils. There was a significant amount of debris in the bottom of the drawer. An overlying stainless steel shelf contained dust and debris and various stains/splashes on the underside of the shelf. A commercial mixer had various dried…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-08 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess and implement physician ordered treatment to maintain range of motion for one of six residents reviewed with range of motion concerns (Resident 52). Findings include: Clinical record review for Resident 52 revealed a current physician's order dated August 10, 2023, that instructed staff to apply a right hand splint at all times except for care, remove daily for care. Clinical record review for Resident 52 revealed a current care plan that indicated the resident had an activities of daily living self care performance deficit related to the medical history and requires staff assistance for dressing, personal hygiene, bed mobility, and toilet use. An intervention included a right hand splint at all times except for care. A significant change Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 29, 2024, noted facility staff assessed Resident 52 as having a BIMS (Brief Interview for Mental Status) of 6,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-08 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure resident participation in formulating an advance directive for one of four residents reviewed for advance directive concerns (Resident 127). Findings include: Clinical record review for Resident 127 revealed a Medical Treatment Guidelines document (form the facility utilized to document a resident and/or resident's responsible party participation in decisions regarding actions taken in the event of a medical emergency) signed by Resident 127 on [DATE], that indicated she desired full resuscitation as part of her medical care decisions. A physician's order instructed staff to provide Full Code treatment (medical personal would do everything possible to save life in a medical emergency) for Resident 127 from [DATE], to [DATE]. A quarterly MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated [DATE], assessed Resident 127 as cognitively…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 35 residents reviewed (Resident 143). Findings include: Clinical record review for Resident 143 revealed a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities: evaluate all applicants for serious mental illness and/or intellectual disability, offer all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings), and provide all applicants the services they need in those settings) completed July 17, 2024, that indicated she had a positive screen, and that she required a Level II PASSAR. A Department of Human Services Office of Mental Health and Substance Abuse Services letter dated July 25, 2024, determined that Resident 143 was eligible for mental health services and that the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a pacemaker for one of 35 residents reviewed (Resident 176). Findings Include: Clinical record review for Resident 176 revealed a medical history that included the presence of a cardiac pacemaker (surgically implanted device used to control the electrical activity of the heart and regulate the heartbeat). Review of a significant change Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated September 17, 2024, noted facility staff assessed Resident 176 as having a BIMS (Brief Interview for Mental Status) of 5, which indicated severe cognitive impairment. The MDS also noted the presence of a cardiac pacemaker. Review of documentation titled Electrophysiology Visit for Resident 176 dated August 19, 2024, revealed the resident had a biventricular pacemaker implanted on March 5, 2020. Review of Resident 176's clinical record on October 5, 2024, at 1:49 PM revealed no care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-10-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the use of medical devices for three of 35 residents reviewed (Residents 66, 155, and 167). Findings include: Observation on October 5, 2024, at 10:49 AM revealed Resident 155 was in her room with a sling to her left arm and shoulder immobilizing it. Review of Resident 155's clinical record revealed nursing documentation dated September 20, 2024, at 6:20 PM indicating that nursing staff found Resident 155 on the floor. The facility sent Resident 155 to the hospital on September 21, 2024, at 3:02 PM for continued complaints of left shoulder pain and a positive x-ray for shoulder fracture. Nursing documentation dated September 21, 2024, at 9:50 PM revealed that Resident 155 returned from the hospital with no new orders. Nursing documentation dated September 22, 2024, at 10:19 AM indicated that nursing staff sent a referral to therapy due to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documents, clinical record review, and staff and resident interview, it was determined that the facility failed to implement appropriate interventions to prevent a fall for one of 11 residents reviewed for falls (Resident 33). Findings include: Clinical Record review for Resident 33 revealed a nursing progress note dated July 5, 2024, at 10:45 PM that indicated a nurse aide was changing Resident 33's brief and bed linen, when she rolled her away from her, and she rolled onto the floor on the right side of the bed. She was noted to have a 10-centimeter (cm) x 10 cm skin tear on her left elbow, an 8 cm x 8 cm skin tear on her right elbow, and a 3 cm x 3 cm closed hematoma (a collection of blood under the skin that can look like a bad bruise) above her left eyebrow. The note also indicated that the new intervention would be to utilize two staff when rolling the resident. Review of Resident 33's active care plan dated June 17, 2024, revealed that there was no current intervention to indicate the number of staff required to safely roll her in bed. Her fall care plan…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-08 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for two of five residents reviewed (Resident 84 and 195). Findings include: Review of Resident 195's clinical record revealed a form entitled Interdisciplinary Team Evaluation dated December 19, 2023, indicating that the team recommended Resident 195's physician consider a gradual dose reduction of Resident 195's Buspar (an antidepressant), Seroquel (a psychoactive medication used to treat mood disorders) and Trazodone (an antidepressant). Resident 195's physician responded to the recommendation indicating that patient still with outbursts and needs her ABH gel (a combination of medications used to treat anxiety), not able to decrease doses. Resident 195's physician refers to a medication that is not listed on the recommendation list and does not provide a clinical rationale as to why the listed medications cannot have a gradual dose reduction. An Interdisciplinary Team Evaluation dated June 24, 2024,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for one of six residents reviewed for infection prevention and control concerns (Resident 87). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Clinical record review for Resident 87 revealed a plan of care initiated by the facility on June 7, 2024, to address Resident 87's need for Enhanced Barrier Precautions (for an indwelling medical device and a chronic wound)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-08 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to ensure a safe and clean environment in the facility's main kitchen. Findings include: Observation in the main kitchen area on [DATE], at 10:38 AM revealed a first aid kit attached to the wall. Located on the top exterior of the kit were the following: a significant build-up of dust, four antiseptic towelettes that expired [DATE], an open triangular bandage box with no bandages, and burn spray with the plastic cap removed that expired [DATE]. The interior of the first aid kit contained multiple empty packages, alcohol cleansing pads that expired [DATE], and a container of burn treatment gel that had one open gel packet that was put back in the box with the others that had expired on [DATE]. The above information was reviewed with the Nursing Home Administrator on [DATE], at 1:35 PM. 28 Pa. Code 201.18 (b)(1)(3) Management

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-09 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, as well as staff and resident interviews, it was determined that the facility failed to ensure self-determination for resident's choices related to wake time schedules for 21 of 34 residents sampled (Residents 1, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 29, 30, and 31). Findings include: Clinical record review for Resident 1 revealed a diagnosis list that included dementia (a loss of cognitive function that is caused by the permanent damage or death of the brain's nerve cells, or neurons) and a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated March 11, 2024, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 7, which indicated severe cognitive impairment. Clinical record review for Resident 9 revealed a diagnosis list that included dementia and a significant change MDS dated [DATE], that noted facility staff assessed the resident as having a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to properly store, secure, and label resident medications and biologicals on two of five nursing units (Rose Nursing Unit and [NAME] Nursing Unit, Residents 6 and 8). Findings include: Observation of the [NAME] Nursing Unit on April 9, 2024, at 5:50 AM revealed a tube of Calmoseptine (a topical medication used to treat various skin conditions) labeled with Resident 8's name in a corner staff seating area just off the main hallway. There were no staff observed in the area at the time and the tube was easily accessible to anyone passing by. Observation of the [NAME] Nursing Unit on April 9, 2024, at 5:55 AM revealed a tube of Calmoseptine labeled with Resident 6's name unsecured on top of a treatment cart in the hallway outside of resident rooms. A concurrent interview with Employee 3, licensed practical nurse, revealed that the medication should be secured in the treatment cart. Observation of the [NAME] Nursing Unit wound…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection regarding transmission-based precautions on one of five nursing units ([NAME] Nursing Unit; Resident 1). Findings include: Review of the policy entitled, Linens - Isolation, noted that staff will place dirty linens of any resident on barrier precautions in a yellow laundry bag and it will be tied. This will prevent potentially contaminated linens or laundry from being carried out into the hallway before being placed in a dirty linen hamper. Staff, wearing gloves, will take the used yellow bags out of the resident's room and immediately place the yellow bags in the linen chute located in the dirty utility rooms. Staff will then remove their gloves and wash their hands immediately after handling these potentially contaminated linens/yellow bags. Review of the policy entitled, Infection Control Transmission-Based…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, review of select facility policies and procedures, and responsible party and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the use of outside resources for one of nine residents reviewed (Resident 1). Findings include: Review of the facility's current policy entitled Consults, indicates that the responsible party should be involved whenever possible. If the responsible party wishes to take the resident to appointments and is deemed safe that is an option. If the resident is competent and able to answer questions in the appointment, the resident may not need an attendant to go into the actual appointment. If they wish an attendant to go into the actual appointment, one will be arranged to go with the resident. Review of Resident 1's clinical record revealed that the facility initially admitted her in 2017. Resident 1 has a diagnosis of dementia, depression, cognitive communication deficit, mood disturbance, psychotic disturbance, and anxiety. The facility assessed Resident 1 as being not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-29 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility policies, observation, and staff interview, it was determined that the facility failed to promote resident dignity and ensure the privacy of residents for eight of eight residents observed (Residents 15, 20, 46, 67, 120, 126, 201, and 205). Findings include: Review of the Dignity Policy, revealed a purpose of the policy is to promote care for residents in a manner and in an environment that maintains or enhances a resident's dignity and respect in full recognition of his or her individuality. The policy further noted that staff in their interactions with residents will carry out activities that assist residents to maintain and enhance his/her self worth. One of the activities included respecting residents' private space and property, which included knocking on doors and requesting permission to enter. Observation on September 26, 2023, at 10:47 AM revealed that Employee 3, clerk and licensed practical nurse, entered Resident 46's and Resident 20's room to inquire about dietary choices without knocking or announcing her visit prior to entry.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-29 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion and mobility for two of five residents reviewed (Residents 44 and 176). Findings include: Clinical record review for Resident 44 revealed a care plan from June 1, 2023, through July 10, 2023, for staff to provide restorative ambulation with limited assist and a walker to and from the bathroom and dining room as tolerated. Review of task documentation for Resident 44 for July 2023, revealed that staff did not document completion of the restorative task on the following dates: July 2, 4, and 7, 2023 Further review for Resident 44 revealed a current care plan for staff to provide restorative ambulation 50 to 150 feet with supervision and with a rolling walker as tolerated Review of task documentation for Resident 44 for July, August, and September 2023, revealed that staff did not document completion of the restorative task on the following dates: August 3, 4, 5, 6, 12, 19, and 20, 2023 September 2, 3, 4, 9, 10, 16, 17, 23, and 24,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-29 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility policies and procedures, and staff and resident interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection regarding transmission-based precautions on two of five nursing units (Rehab and [NAME]; Residents 10, 29, 55, 83, 107, and 174 ). Findings include: Review of the policy entitled Transmission Based Precautions, last reviewed on July 25, 2023, indicates that when a resident is on transmission-based precautions, appropriate notifications in the room or unit entrance door so that personnel or visitors are aware of the need for and type of precautions. The signage informs the staff of the type of precautions, instructions for use of personal protective equipment (PPE, gowns, gloves, masks, etc.), and/or instructions to see the nurse before entering the room. Interview with Resident 83 on September 26, 2023, at 10:51 AM revealed that she was on an antibiotic for an infection but could not recall for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to thoroughly investigate an incident to rule out potential neglect for one of one resident reviewed (Resident 116). Findings include: Clinical record review revealed the facility admitted Resident 116 on September 1, 2022. A review of nursing documentation dated February 18, 2023, at 9:50 AM revealed a nurse aide was providing morning care and rolled Resident 116 to her right when she fell out of bed. Resident 116 stated she struck her head on the nightstand and had a small abrasion on her finger. A review of the facility investigation into Resident 116's February 18, 2023, fall revealed the facility's interdisciplinary team's follow-up action dated February 20, 2023, noting Resident 116 is to have two staff members for care. A review of Resident 116's plan of care for her activities of daily living deficit initiated on February 20, 2027, revealed Resident 116 required two people for care. Further review of Resident 116's clinical record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide appropriate bathing assistance for residents dependent on staff assistance for 2 of 2 residents reviewed (Residents 22 and 97). Findings include: An interview with the Director of Nursing on September 27, 2023, at 1:10 PM revealed that the facility baths residents according to their preference. Clinical record review for Resident 22 revealed an annual Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 10, 2023, that revealed nursing staff assessed Resident 22 as totally dependent on one-person physical assistance for bathing. A review of Resident 22's current care plan last reviewed on July 17, 2023, revealed a care plan for Activities of Daily Living (ADL) self-care deficit that indicated Resident 22's bathing preference was to receive a shower. A review of PCC (Point Click Care, a computerized documentation system) task documentation (documentation of the care provided to the resident) for her…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to properly assess and monitor pressure areas for one of eight residents reviewed (Resident 187) and implement ordered pressure sore prevention devices for one of eight residents reviewed (Resident 205). Findings include: The policy entitled Pressure Injury-Risk Assessment, Prevention of Skin Breakdown and Skin Care Management, last reviewed July 25, 2023, indicates that pressure and non-pressure wounds will be monitored at least weekly with measurements and the status of the wound by documenting in the medical record. Review of Resident 187's clinical record revealed a risk assessment dated [DATE], indicating that the facility assessed her as being at moderate risk of developing pressure ulcers. A nursing note dated July 20, 2023, at 7:32 AM indicated that nursing staff assessed Resident 187's buttocks and indicated that a previous pressure ulcer area on her right buttock had resolved. A…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls for two of six residents sampled (Residents 1 and CR1). Findings include: Clinical record review for Resident 1 revealed the resident had dementia (a condition with progressive loss of thinking, memory changes, and personality change) and Parkinson's Disease (a condition that causes unintended tremors and movements such as shaking, stiffness, and difficulty with balance and coordination). Clinical record review for Resident 1 revealed current physician order's that were initiated January 31, 2023, for a standard wheelchair with a coccyx (tailbone) cut-out cushion and Dycem (non-slip pad provided on seating to prevent slipping and provide stabilization) underneath and on-top of the cushion, and bilateral elevation leg rests. If the cut-out cushion is unavailable, use a standard pressure relieving cushion. Review of a nursing progress note dated February 5, 2023, at 9:10 PM for Resident 1 revealed that the resident had fallen. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
BOYER, BETSYIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 11/01/2013
BICKFORD, LAWRENCEIndividualCORPORATE OFFICERsince 11/01/2013
CHARLES, THOMASIndividualCORPORATE OFFICERsince 10/14/2016
RAUP, CARLIndividualCORPORATE OFFICERsince 11/01/2013

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$23.3M
Net patient revenuemost recent cost report
-25.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 74%Medicare 2%Other / private 24%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$357per resident / day
operating cost
$10,866per month
≈ monthly operating cost
$285per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.

Typical monthly cost in Pennsylvania
$11,954/mo
Nursing home (semi-private)
$13,688/mo
Nursing home (private)
$6,480/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395779. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next