Bethlehem North Skilled Nursing And Rehabilitation
2029 Westgate Drive, Bethlehem, PA 18017 · For profit - Corporation · 217 certified beds · (610) 861-0100 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 36% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 4 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.3% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.7% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.3% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.5% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 30.8% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.7% | 20.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 84.7% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.5% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.1% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.8% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 58.2% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.0% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.8% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.52 | 1.62 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.92 | 1.18 | 1.80 | better |
§ 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.
46.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 195 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 34.4% 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 96 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.1%CMS range 41.1–53.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 7.8%CMS range 5.2–11.4 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 34.4% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 39.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 25.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 97.7% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 4.2–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.75 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 217 beds and averages 202.1 residents a day — about 93% occupied, or roughly 15 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.88 hrs/resident/day on weekends vs 3.36 on weekdays — 14% thinner on weekends. RN hours go from 0.53 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% 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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · E2026-05-12 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 facility policy review, clinical record review, resident interview, and review of facility documentation, it was determined that the facility failed to report alleged violations involving abuse to the State Survey Agency for six of six sampled residents. (Residents 1, 2, 3, 4, 5, 6)Findings Include: Review of the facility policy entitled, Abuse Prohibition, last reviewed November 14, 2025, revealed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee would report allegations that involved abuse not later than two hours after the allegation was made and report allegations to the appropriate state and local authorities within 24 hours if the event did not result in serious bodily injury. Clinical record review revealed that Resident 1 had diagnoses that included major depressive disorder, bipolar disorder, anxiety, and post-traumatic stress disorder (PTSD). Review of facility documentation revealed that on April 7, 2026, the resident…
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.
- Potential for harm · Dcited before2026-04-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 notify the responsible party of a change in the resident's medical condition for one of one resident receiving hospice services. (Resident R1) Findings include:Clinical record review revealed that Resident R 1 was admitted to the facility with diagnoses that included liver cancer. The resident was placed on hospice services on March 2, 2026, with a physician's order for a narcotic pain medication (morphine sulfate) to be administered orally every two hours as needed for pain. Review of the Medication Administration Record (MAR) for April 2026, revealed that the medication was administered to the resident on April 10, 2025, at 2:40 a.m. There was a lack of documentation to support that the resident's responsible party was made aware of the resident's change in medical status and medication.In an interview on April 10, 2026, at 11:45 a.m., the Nursing Home Administrator confirmed that the responsible party was not made aware of the change in medical condition and the administration of…
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.
- Potential for harm · Fcited before2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department. Findings include:Review of the facility policy entitled, Use-by Dating Guidelines, dated January 15, 2026, revealed that staff were to discard prepared foods after 72 hours and frozen foods after 45 days of opening.Review of the facility policy entitled, Department Sanitation, dated January 15, 2026, revealed that staff were to assure that the pot and pan sink were properly filled with the sanitizing solution at the appropriate concentration. Observations during the kitchen tour on February 10, 2026, at 10:43 a.m., revealed the following:Inside the stockroom reach-in freezer, there was food debris on the bottom. In the reach-in cooler, there was a container of yogurt not dated and a cup of apple juice labelled use-by December 17, 2025. In the dry storage area, there were four packages of mousse mix removed from the original packaging that were not dated. There were two opened bulk containers of croutons and…
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.
- Potential for harm · E2026-02-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for five of 35 sampled residents. (Residents 8, 12, 16, 18, and 159)Findings include: Review of the policy entitled, Medication Administration General Guidelines, last reviewed January 15, 2026, revealed staff were to obtain and record vital signs, if necessary, prior to medication administration and document necessary information in the Medication Administration Record (MAR). Clinical record review revealed that Resident 8 had diagnoses that included hypertension (high blood pressure) and heart failure. A physician's order dated December 12, 2025, directed staff to administer a medication (carvedilol) two times a day for hypertension and heart failure. Staff were not to administer the medication if the resident's blood pressure was less than 100 millimeters of mercury (mm/Hg) or if the heart rate (the number of times a heart beats in one minute) was less than 60 beats per minute (bpm). Review of Resident 8's December…
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.
- Potential for harm · D2026-02-12 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 35 sampled residents. (Residents 18, 204)Findings include: Review of the facility policy entitled, Medications: Self-Administration, last reviewed January 15, 2026, revealed that the facility was to assess and determine whether self-administration of medications was safe and clinically appropriate based on the resident's functionality and health condition. The policy also stated that a physician/advanced practice provider order was required for medication self-administration, the facility was to document in the resident's care plan that the resident was able to self-administer medication, and, if applicable, the resident was to be provided with a secure, locked area to maintain medications. Clinical record review revealed that Resident 18 had diagnoses that included end-stage kidney disease and dependence on kidney dialysis (a procedure that cleans the blood in…
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.
- Potential for harm · D2026-02-12 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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, resident interview, facility documentation review, and staff interview, it was determined that the facility failed to obtain written authorization to manage personal funds for one of 35 sampled residents. (Resident 160)Findings include: Clinical record review revealed that Resident 160 was admitted [DATE], and had diagnoses that included diabetes and hypertension (high blood pressure). The Minimum Data Set assessment, dated January 21, 2026, indicated that the resident was able to communicate her needs and was able to be understood. In an interview on February 10, 2026, at 11:30 a.m., Resident 160 stated that she had received a letter from Social Security stating that she will no longer receive her money and that the facility will manage her funds. She further stated that she did not authorize the facility to become her representative payee and that the facility took her money without her permission. A review of the representative payee authorization forms that were sent 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.
- Potential for harm · D2026-02-12 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for two of five newly hired employees. (Employees 1 and 5)Findings include:A review of the facility policy entitled, Abuse Prohibition, dated January 15, 2026, revealed that the facility was to conduct screenings for potential hires. A review of the facility policy entitled, Hiring, dated January 15, 2026, revealed that the facility was to check references and to verify the license required for the position for all potential hires. Employee 1 had been working in the facility as the Administrator since January 20, 2026, and an inquiry to the state licensure board was not completed until February 11, 2026.Employee 5 had been working in the facility as a nurse aide since November 4, 2025, and a reference check was not completed until November 29, 2025.In an interview on February 20, 2026, at 1:15 p.m., the Director of Human Resources Operations Partner…
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.
- Potential for harm · Dcited before2026-02-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interviews, it was determined that the facility failed to provide assistance with bathing for two of 36 sampled residents. (Resident 127 and 192)Findings include: Clinical record review revealed that Resident 127 had diagnoses that included a cerebral infarction (stroke) affecting the right side and diabetes with polyneuropathy (damage to the peripheral nerves causing burning pain, numbness, tingling, and weakness). According to two Minimum Data Set (MDS) assessment dated [DATE], the resident required extensive assistance from staff for activities of daily living (ADLs) and was totally dependent on staff for bathing. A review of the care plan revealed that the resident required assistance with hygiene and that staff was to provide a shower or bed bath twice a week. Review of nurse aide documentation for January and February 2026, revealed the resident was scheduled for a bath or shower on January 15 and 17, 2026, and did not receive one. In an interview on…
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.
- Potential for harm · D2026-02-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of four sampled residents. (Resident 1)Findings Include: Clinical record review revealed that Resident 1 had diagnoses that included open wound of the lower back and pelvis region (bed sore) and left heel pressure ulcer. A physician's order dated August 20, 2025, directed staff to apply a heel suspension device (a device to prevent and treat pressure sores) to the right and left heels while in bed. Review of the comprehensive care plan revealed that Resident 1 was at risk for skin breakdown. Multiple observations on February 10, 2026, and February 11, 2026, between 10:00 a.m. and 2:00 p.m., revealed Resident 1 in bed, and the heel suspension device was not applied. In an interview dated, February 11, 2026 at 12:36 p.m., Resident 1 stated sometimes the staff would apply a pillow under her heels or heel boots and that it all depended on who was working. In an interview on February 12, 2026, at 10:45 a.m.,…
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.
- Potential for harm · Dcited before2026-02-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for two of 35 sampled residents. (Residents 4 and 9) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included muscle weakness, bladder cancer, and chronic obstructive pulmonary disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 4 was cognitively intact. On January 16, 2026, the physical therapist recommended a restorative nursing program (RNP) for ambulation for Resident 4 to use a rolling walker and contact guard assistance from staff to walk 100 to 200 feet for 15 minutes daily. There was no documented evidence that the facility provided the recommended RNP. In an interview on February 12, 2026, at 10:30 a.m., Resident 4 stated that he had not been offered the RNP program for ambulation and he would not have refused it. In an interview on…
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.
Show the remaining 18 citations
- Potential for harm · D2026-02-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 policy review, clinical record review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of 35 sampled residents. (Resident 13) Findings include: Review of the facility policy entitled, Continence Management, last reviewed January 15, 2026, revealed that staff was to complete a urinary incontinence and/or bowel incontinence assessment upon admission and quarterly as part of their care planning process, and whenever there was a change in a resident's continence. The purpose was to provide appropriate treatment and services for residents with urinary and bowel incontinence and restore continence to the extent possible. The facility was to develop individualized interventions and a plan of care based on information from the assessment and voiding records. Clinical record review revealed that Resident 13 was admitted [DATE], and had diagnoses of hypertension (high blood pressure) and…
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.
- Potential for harm · Dcited before2026-02-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess nutritional status for one of three sampled residents at risk for weight loss. (Resident 144)Findings include: Review of the facility policy entitled, Weights and Heights, last reviewed January 15, 2026, revealed that if a body weight of a resident is not as expected, reweigh the resident within 24 hours. A licensed nurse would notify the registered dietitian (RD) of any significant weight changes, and the notification would be documented in a progress note. Clinical record review revealed that Resident 144 had diagnoses that included myasthenia gravis (autoimmune disorder causing fluctuating weakness in voluntary muscles), cerebral infarction (stroke), and mild protein-calorie malnutrition. Review of the care plan revealed that the resident was at risk for malnutrition and the intervention was for staff to monitor for changes in nutritional status. On February 2, 2026, the resident weighed 188 pounds (lbs.). On February 5, 2026,…
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.
- Potential for harm · D2026-02-12 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 35 sampled residents. (Resident 139) Findings include: Clinical record review revealed that Resident 139 was admitted to the facility on [DATE], with diagnoses that included PTSD, major depressive disorder, anxiety, and mood disorder. The Minimum Data Set assessment dated [DATE], revealed that the resident had a diagnosis of PTSD and displayed symptoms of feeling tired, feeling hopeless, having trouble falling asleep, and feeling bad. There was a lack of documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on February 12, 2026, at 9:08 a.m., the Social Work…
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.
- Potential for harm · D2026-02-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to evaluate the need to provide pneumococcal disease vaccines in accordance with facility policy for two of five residents whose vaccines were reviewed. (Residents 19, 47) Findings include: Review of the facility policy entitled, Pneumococcal Vaccination, last reviewed January 15, 2026, revealed that upon admission, the facility would assess each resident to determine if they had been previously vaccinated for pneumococcal disease and offer the vaccine if the resident had not received it or was not up to date according to the Center for Disease Control's Pneumococcal Vaccine Timing for Adults guidelines. Staff were to document education, including benefit of vaccination, and whether the resident received the vaccination or declined in the electronic medical record. Clinical record review revealed that Resident 19 was admitted to the facility on [DATE]. The resident received the pneumococcal…
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.
- Potential for harm · D2026-02-12 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 facility policy review, clinical record review, staff interview, and review of the Centers for Disease Control and Prevention guidelines, it was determined that the facility failed to offer coronavirus-19 (COVID-19) vaccines in accordance with facility policy to two of five residents whose vaccines were reviewed. (Residents 1, 19)Findings include: Centers for Disease Control and Prevention (CDC) guidance dated November 19, 2025, stated that staying up to date and getting the 2025-2026 COVID-19 vaccine is especially important for those living in a long-term care facility. The policy entitled Policy for COVID-19 Vaccination, last reviewed January 15, 2026, revealed the facility was to offer the COVID-19 vaccine to healthcare workers and the residents when it became available, consents for vaccination were to be obtained and if refused a declination was to be signed. The policy also stated the facility would provide education on the risks versus benefits of the vaccine and would be responsible 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.
- Potential for harm · D2025-03-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 39 sampled residents. (Resident 104) Findings include: Clinical record review revealed that Resident 104 had diagnoses that included polyneuropathy (a condition where peripheral nerves are damaged) and dementia. Review of the Minimum Data Set assessment, dated December 15, 2024, revealed Resident 104 was dependent on staff for activities of daily living, including toileting, dressing, and personal hygiene. Review of the care plan revealed that Resident 104 was at risk for falls with an intervention for staff to keep commonly used articles within easy reach and reinforce the need to call for assistance. On March 5, 2025, at 11:16 a.m., Resident 104 was observed in bed with the call bell on the floor next to the bed. Resident 104 was observed again at 12:19 p.m. and 2:40 p.m., in bed with the call bell on the floor and out of reach. In an interview on March 6, 2024, at 1:45 p.m., the Assistant Director of Nursing confirmed that the resident's…
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.
- Potential for harm · Dcited before2025-03-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a change in condition for three of four sampled residents who experienced significant weight loss. (Residents 44, 46, and 164) Findings include: Review of the facility policy entitled, Weights and Heights, last reviewed, November 18, 2024, revealed that staff would notify a resident's representative of a significant weight change. Review of the facility policy entitled, Change in Condition: Notification of, last reviewed November 18, 2024, revealed that the facility must immediately notify the resident's representative when there is a significant change in a resident's condition. Clinical record review revealed that Resident 44 had sarcopenia and dementia. On November 16, 2024, the resident weighed 235 pounds (lbs.). On December 17, 2024, the resident weighed 209.5 lbs., which reflected a 25.5 lb. (10.8%) weight loss. On January 6, 2025, the resident…
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.
- Potential for harm · Dcited before2025-03-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observation, clinical record review, and staff and resident interviews, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for three of 39 sampled residents. (Residents 1, 99, 183) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included muscle weakness. Review of the care plan revealed that the resident required assistance from staff for activities of daily living (ADLs). On March 4, 2025, the resident was observed in her room. Her nails were long and dirty. She stated she preferred her nails to be kept short, staff had not offered assistance with nail care, and she had not refused. On March 5, 2025, at 12:04 p.m., the resident was again observed in her room. Her nails remained long and dirty. She stated that staff had not offered assistance with nail care. There was no evidence of refusals. Clinical record review revealed that Resident 99 had diagnoses that included dementia and dermatitis (inflammation of the skin). Review of the Minimum Data Set (MDS) assessment, dated February 7,…
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.
- Potential for harm · Dcited before2025-03-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement interventions to prevent a decline in range of motion for one of 39 sampled residents. (Resident 159) Findings include: Clinical record review revealed that Resident 159 had diagnoses that included stroke and depression. Review of the care plan revealed that the resident had self-care deficits and required assistance from staff for activities of daily living. A physician's order dated December 27, 2024, directed staff to apply a soft hand splint to the right hand once per day, during the day (7:00 a.m. through 3:00 p.m.) shift. Review of an occupational therapy discharge assessment dated [DATE], revealed that the resident was to wear a right palm grip which was to be placed on her hand with morning care. There was no evidence that staff updated the resident's clinical record to include the correct orthotic device, per the therapy discharge summary. On March 4, 2025, at 12:33…
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.
- Potential for harm · Dcited before2025-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement safety measures related to smoking for one of one sampled residents who smoke. (Resident 171) Findings include: Review of the facility policy entitled, Smoking, last reviewed November 18, 2024, revealed that resident smoking supplies, which included cigarettes and lighters, would be labeled with the resident's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet at the nurses' station. Clinical record review revealed that Resident 171 had diagnoses that included depression and anxiety. Review of the care plan revealed that the resident was independent for smoking and the interventions were for staff to educate the resident on the smoking policy and monitor for compliance with the policy. On March 4, 2025, at 12:15 p.m., Resident 171 was observed in his room. He stated that he smoked cigarettes and that his smoking supplies, which included cigarettes and a lighter, were kept in his personal…
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.
- Potential for harm · Dcited before2025-03-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess weight loss for two of four sampled residents at risk for weight loss. (Residents 164 and 46). Findings include: Review of the facility policy entitled, Weights and Heights, last reviewed November 18, 2024, revealed that a licensed nurse would notify the registered dietitian (RD) of any significant weight changes and the notification would be documented in a progress note. Clinical record review revealed that Resident 164 had diagnoses that included traumatic brain injury and dysphagia. Review of the care plan revealed that the resident was at risk for nutritional problems and the intervention was for staff to monitor for changes in nutritional status. On December 19, 2024, the resident weighed 229 pounds (lbs.). On December 23, 2024, the resident weighed 217.4 lbs. On December 24, 2024, the resident weighed 217.0 lbs., which confirmed a significant weight loss…
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.
- Potential for harm · D2025-03-06 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of 39 sampled residents. (Resident 159) Findings include: Clinical record review revealed that Resident 159 had diagnoses that included stroke and depression. Review of the care plan revealed that the resident was at risk for nutrition problems and required adaptive equipment. The intervention was for staff to provide a curved right spoon. On March 4, 2025, at 12:33 p.m., the resident was observed in bed with her lunch tray on the table. The tray ticket indicated that the resident was to have a curved spoon. Observation of the resident's meal tray revealed that she had only a regular spoon. The resident stated the she was to have a curved spoon and she often does not receive it on her meal trays. The resident was observed on March 5, 2025, at 8:16 a.m., with her breakfast tray and at 12:20 p.m., with her lunch tray. At both observations, the resident received a regular spoon, the curved spoon was not in place. 28 Pa.…
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.
- Potential for harm · Dcited before2025-03-06 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, it was determined that the facility failed to serve food under sanitary conditions in the kitchen. Findings include: During observation of the tray line service on March 5, 2025, at 11:18 a.m., dietary employee (DE) 1 was wearing gloves and assembling resident meals on the tray line. DE 1 proceeded to leave the tray line while pushing a rolling cart to obtain plates; she did not change her gloves or perform hand hygiene before she returned to the tray line. DE 1 continued to assemble resident meals wearing the same gloves. DE 1 was then observed wiping the gloves on her clothing on two different occasions; she did not change her gloves or perform hand hygiene. DE 1 then picked up cooked chicken from the steam table pan with her hands, while wearing the same gloves, and placed it onto resident meal trays six different times. DE 1 did not change her gloves or perform hand hygiene during the observation period. 28 Pa. Code 201.18(b)(3) Management.
- Potential for harm · Dcited before2024-02-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess and implement safety measures related to smoking for one of one sampled residents who smoke. (Resident 31) Findings include: Review of the facility policy entitled, Smoking, last reviewed August 7, 2023, revealed that smoking would be permitted in designated areas and that residents would be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, would be supervised. Clinical record review revealed that Resident 31 had diagnoses that included diabetes, chronic obstructive pulmonary disease, and an amputation of the left leg below the knee. According to the Minimum Data Set assessment, dated November 2, 2023, the resident had no cognitive impairment. In an interview on February 15, 2024 at 8:44 a.m., Resident 31 reported smoking on a regular basis. Observations on February 15, 2024, at 11:05 a.m. and 2:55 p.m., revealed Resident 31 outside the front of the building…
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.
- Potential for harm · D2023-12-28 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 clinical record review and interview, it was determined that the facility failed to ensure that bathing was provided to a resident for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included gangrene of upper and lower extremities, and adjustment disorder with anxiety. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and was dependent for self care including showering. A review of the care plan revealed that the resident was at risk for an Activites of Daily Living deficit due to physical limitations. There was an intervention for staff to assist with bathing and showering as needed. In an interview on December 28, 2023, at 3:00 p.m., Resident 1 stated that she did not get assistance with her showers as she preferred two times a week. The resident further stated that her scheduled shower days were on Mondays and Thursdays and that she had not consistently received assistance…
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.
- No harm found · B2026-02-12 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of four nursing units. (4th floor)Findings include:In a group interview on February 10, 2026, at 10:00 a.m., Residents 12, 15, 49, and 166 reported that hot food was frequently served cold.Review of facility documentation entitled, Food and Nutrition Services Test Tray Evaluation, revealed that the hot main entree, starch, and vegetable should be greater than 140 degrees Fahrenheit (F) at point of service to the resident. Results of a test tray audit conducted on February 11, 2026, at 12:26 p.m., after the last resident meal tray was served from the dining cart, revealed a smothered chicken thigh was served at a temperature of 115.2 degrees F, the mashed potatoes at a temperature of 115.7 degrees F, and the mixed vegetables at a temperature of 108.5 degrees F. All the food items were cool to taste. In separate interviews on February 11, 2026, between 12:17 p.m. and…
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.
- No harm found · B2026-02-12 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.Findings include:Observation of the trash compactor area on February 10, 2026, at 11:15 a.m., revealed the area adjacent to the compactor had multiple pieces of plastic and paper debris. There was a wrapped, soiled feminine hygiene product, a soiled piece of gauze, multiple used plastic gloves, and a half-eaten chicken drumstick on the ground in front of the compactor. 28 Pa Code 201.18(b)(3) Management.
- No harm found · C2025-03-06 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, it was determined that the facility failed to notify the residents and/or the residents' representative(s) of their appeal rights and Ombudsman information in writing upon transfer from the facility for five of five sampled residents who were transferred to the hospital. (Residents 14, 57, 101, 133, and 164) Findings include: Clinical record review revealed that Resident 14 was transferred to the hospital on February 5, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or legal representative was provided information regarding appeal rights and the Ombudsman upon transfer to the hospital. Clinical record review revealed that Resident 57 was transferred to the hospital on December 4, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or legal representative was provided information regarding appeal rights and the Ombudsman upon transfer to the hospital. Clinical record review revealed that Resident 101 was…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 2 of 5 | 3.5 | -1.5 vs chain |
The other 183 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 183; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GENESIS PM PA OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/15/2022 |
| FC-GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GHC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| SUN HEALTHCARE GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 11/15/2022 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| CALLAZO, NANCY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/29/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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.
About 82% 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. This home reported $7.9M paid to related parties — landlords or management companies under common ownership — equal to about 36% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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
Straight from this home’s Medicare cost report (CMS, FY2024). 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
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.
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 395527. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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 →
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