Bethlehem South Skilled Nursing And Rehabilitation
2021 Westgate Drive, Bethlehem, PA 18017 · For profit - Corporation · 227 certified beds · (610) 865-6077 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $27,378 in federal fines (most recent 2026-04-29)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- 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 | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 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 | 20.1% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.3% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 9.5% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.4% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.4% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.5% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.1% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.4% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.5% | 17.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 32.2% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.7% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.1% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.59 | 1.62 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.49 | 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.
42.3% 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 153 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.2% 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 80 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 42.3%CMS range 34.8–50.1 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.9–13.4 | 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 | 51.2% | 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 | 52.5% | 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 | 45.0% | 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 | 99.1% | 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 | 98.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 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 | 0.9% | 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 | 5.7%CMS range 3.5–8.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 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 227 beds and averages 195.0 residents a day — about 86% occupied, or roughly 32 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 2.90 hrs/resident/day on weekends vs 3.47 on weekdays — 17% thinner on weekends. RN hours go from 0.51 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.
- Immediate jeopardy · J2026-06-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents were free from abuse that resulted in actual physical harm for one of seven sampled residents (Resident 2) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance.Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed on November 14, 2025, revealed that Center staff were to do all that was within their control to prevent occurrences of abuse for all patients. Actions to prevent abuse would include identifying, correcting, and intervening in situations in which abuse was more likely to occur. The Center was responsible for identifying patients who had a history of disruptive or intrusive interactions or who exhibited other behaviors that made them more likely to be involved in an altercation. Clinical record review revealed that Resident 1 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.
- Potential for harm · D2026-06-30 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 attempt non-pharmacological interventions prior to administering an anti-anxiety medication for one of six sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included neurocognitive disorder with Lewy bodies (progressive brain disease caused by abnormal protein deposits), cerebral infarction (stroke), and insomnia (sleep disorder). Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired. A review of the care plan revealed that the resident exhibited physical and/or sexual behaviors related to poor impulse control. On May 22, 2026, a physician ordered staff to administer an anti-anxiety medication (lorazepam) every six hours as needed for agitation. Review of Resident 1's Medication Administration Record revealed that staff had administered the lorazepam seven times in May 2026 and 11 times in June…
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 · D2026-06-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 — the official record, unedited, 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 a comprehensive care plan to meet each resident's needs for one of six sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy Bodies (a disorder that affects brain function) and insomnia (inability to sleep). Review of nursing notes dated June 2, 3, 4, 11, 15, and 26, 2026, revealed that Resident 1 had increased behaviors of wandering into other resident rooms and taking their items. There were no care plan interventions to address Resident 1 wandering into other resident rooms or taking their items.In an interview on June 30, 2026, at 12:25 p.m., the Assistant Director of Nursing confirmed there was no documented evidence that the care plan addressed wandering into other resident rooms or taking their items. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
- Potential for harm · Dcited before2026-06-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and resident interview, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent wandering and accidents for one of six sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy Bodies (a disorder that affects brain function) and insomnia (inability to sleep). The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and was independent for transfers and ambulation (walking). A review of the care plan identified that the resident was at risk for falls. Review of nursing documentation revealed that on May 6, 2026, Resident 1 was wandering throughout the shift. On May 7, 2026, Resident 1 was documented as wandering down the hall all shift, opening doors, and entering resident rooms. On May 9, 2026, a nurse documented…
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 before2026-06-02 · 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of an alteration in treatment for one of four sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disorder caused by abnormal buildup of alpha-synuclein proteins in the brain, dementia with behaviors and insomnia). A Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and was dependent for most of his care. A review of the resident's care plan revealed a problem area of at risk for complications related to the use of psychotropic drugs. On April 29, 2026, a psychiatrist documented that the resident's responsible party had indicated that she did not want the resident restarted on the psychotropic medication Depakote, a medication used to manage manic mood disorders. On May 1, 2026, a nurse…
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 before2026-04-29 · 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
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 assess and document the status of wounds or provide physician ordered treatments to prevent new or worsened pressure ulcers for three or eight sampled residents. (Residents 2, 3, 4)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included Hidradenitis suppurativa (chronic inflammatory skin condition of lumps and cysts in the buttocks, groin, and armpits), peripheral vascular disease (a condition when the blood vessels become narrow), and heart failure. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert, was dependent on staff for activities of daily living (ADL), and was at risk of developing pressure ulcers. A review of the care plan revealed that the resident had limited mobility and had skin breakdown on her left axilla (armpit) and right gluteal fold (the crease that forms beneath the buttocks). A physician's order dated March 2, 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.
- Potential for harm · D2026-04-29 · 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
Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for two of eight sampled residents. (Residents 5, 6) Findings included: Review of the facility policy entitled, Catheter: Indwelling Urinary - Care of, last reviewed January 15, 2026, revealed that the catheter drainage bag must be positioned lower than the bladder, the catheter drainage bag must be emptied when it became half full, and the catheter tubing and drainage bag must be kept off the floor. Clinical record review revealed that Resident 5 had diagnoses that included obstructive uropathy (blockage in the urinary tract), diabetes, and kidney failure. The resident required the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine). On January 27, 2026, the physician ordered the resident to have an indwelling urinary catheter. On April 28, 2026, at 11:00 a.m., the resident was observed in bed with the catheter tube and catheter bag containing urine lying directly…
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 · Ecited before2025-09-05 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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 verify professional license/registration status prior to the start of employment for three of five newly hired employees. (Employees 1, 2, 3)Findings include: A review of the facility policy entitled, Abuse Prohibition, last reviewed February 27, 2025, revealed that the facility would implement an abuse prohibition program through screening of potential hires. The process included screening potential employees for a history of abuse, neglect, or mistreatment of patients which would have included checking with the appropriate licensing boards and registries. Review of personnel files of newly hired employees revealed the following: Employee 1 (E 1) began employment on August 12, 2025. There was no evidence that the facility submitted an inquiry to the state board of nursing before or since E 1 started working in the facility. E 2 began employment on July 29, 2025. There was no evidence that the facility submitted an inquiry to the state nurse aide registry before…
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 · E2025-09-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
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 review of facility policy, clinical record review and resident and staff interview, it was determined that the facility failed to provide adequate treatment and services for respiratory therapy and failed to maintain respiratory equipment in a sanitary manner for four of six sampled residents who utilized respiratory equipment. (Residents 1, 7, 12, 104)Findings include: Review of the facility policy entitled, Respiratory Equipment/Supply Cleaning/Disinfecting, last reviewed February 27, 2025, revealed that the schedule for supply changes for oxygen humidifiers was to be every seven days and as needed for soiling and nebulizer equipment was to be changed daily. Clinical record review revealed that Resident 1 had diagnoses that included pneumonia, asthma, and respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was alert and oriented and that she utilized oxygen therapy. A physician's order dated July 31, 2025, directed staff to administer 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.
- Potential for harm · D2025-09-05 · 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, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 35 residents. (Resident 1)Findings include: Review of the facility policy entitled, Medications: Self-Administration, last reviewed on February 22, 2025, revealed that residents would be evaluated for self-administration of medications, would require a physician's order, and, when applicable, the resident would be provided with a secure, locked area to maintain medications. Clinical record review revealed that Resident 1 had diagnoses that included pneumonia, heart failure, and hypokalemia (low potassium level). Review of the Minimum Data Set (MDS) assessment, dated February 21, 2025, revealed that the resident's cognitive ability was intact. On September 4, 2025, between 11:21 a.m. and 11:37 a.m., Resident 1 was observed sleeping with one pill in a medication cup on the bedside table in front of her.In an interview on September 4, 2025, at 11:37 a.m., LPN 1 confirmed 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.
- Potential for harm · D2025-09-05 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to report an alleged violation of potential neglect for one of 35 sampled residents. (Resident 18 ) Findings include: Review of the facility policy entitled, Abuse Prohibitions, last reviewed February 27, 2025, revealed that the facility prohibited abuse, mistreatment, neglect, and exploitation, for all residents. The facility was to implement abuse prohibition through the following, to include reporting of incidents, investigations, and the facility's response to the results of their investigations immediately upon receiving information concerning a report of suspected neglect or abuse. The designee was to report the allegations involving neglect to the appropriate state and local authorities. Clinical record review revealed that Resident 18 had diagnoses that included chronic obstructive pulmonary disease, intellectual disabilities, and lumbago sciatica (pain in the lower back). 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.
Show the remaining 22 citations
- Potential for harm · Dcited before2025-09-05 · 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, observation, and staff interview, it was determined that the facility failed to ensure that appropriate assistance with oral hygiene was provided to one of 35 sampled residents. (Resident 7)Findings include: Review of the facility policy entitled, Oral Health, last reviewed on February 22, 2025, revealed that oral hygiene would be performed at a minimum of two times per day (morning and night). Clinical record review revealed that Resident 7 had diagnoses that included aphasia (a language disorder that affects a person's ability to communicate), right-sided weakness or paralysis due to a stroke, difficulty swallowing, and the presence of a feeding tube in the stomach. The Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident 7 was cognitively impaired, dependent on staff for Activities of Daily Living (ADLs), and did not eat by mouth. A review of the care plan revealed that the resident had an ADL self-care deficit related to physical limitations 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 before2025-09-05 · 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
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 provide necessary treatment and services to promote healing for one of three sampled residents who had pressure ulcers. (Resident 99) Findings include: Clinical record review revealed that Resident 99 had diagnoses that included multiple sclerosis, a chronic sacral pressure sore, and venous insufficiency. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert, dependent on staff for activities of daily living (ADL), and had a stage four pressure ulcer. On May 13, 2025, the physician's order directed staff to remove the old dressing from the stage four pressure sore, provide cleaning to the sore, and apply packing and a new dressing to the sore daily and when the dressing became soiled. A review of a wound care physician's note dated September 3, 2025, documented the sacral pressure sore remained and directed staff to continue with treatment as ordered. A review of the 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.
- Potential for harm · Dcited before2025-09-05 · 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 staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of six sampled residents with limited range of motion. (Resident 15)Findings include: Clinical record review revealed that Resident 15 had diagnoses that included weakness or paralysis of the left side of the body due to a stroke and communication deficit. The annual Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, dependent on staff for dressing and personal hygiene, and had loss of range of motion. A review of Resident 15's care plan revealed the resident had a loss of range of motion of the left upper extremity. On December 19, 2024, the physician ordered that staff apply a palm guard (a device applied to protect the palm of the hand) to Resident 15's left hand in the morning and remove in the evening. Observations on September 3, 2025, between 10:05 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 before2025-07-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent accidents/hazards for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnosis that included dementia, chronic obstructive pulmonary disease, and emphysema. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident 1 required supervision to touch-assistance for showering or bathing. Review of Resident 1's care plan revealed that the resident was at risk for decreased ability to perform activities of daily living (ADLs) related to limited mobility and required setup assistance for bathing. Review of facility documentation revealed that on July 5, 2025, at 6:15 a.m., Resident 1 requested to shower. At that time, the nurse aide (NA 1) set the resident up in the shower. At 6:25 a.m. NA 1 checked on the resident, Resident 1 was not done showering. NA 1…
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 before2025-07-01 · 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, it was determined that the facility failed to ensure that the physician and responsible party was notified in a timely manner of a change in the residents condition for one of five residents sampled. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility with diagnoses that included diabetes mellitus, dementia and mood disorder. A note by a nurse on June 21, 2025, at 2:45 p.m., noted that the resident had an increase in tiredness, wanted to sleep and had poor meal intake. The resident was observed to have had loose stools on three occasions on the afternoon shift. At 6:29 p.m. the nurse noted that the resident while being fed supper had vomited. The resident's blood pressure was noted to be low. There was no assessment by the nurse following the episode of vomiting. There was no documentation that the physician or responsible party was notified about the changes in Resident CR1's condition. The resident was transferred to the emergency room on June 22, 2025, at 7:30 a.m. due to an acute change…
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 before2024-11-27 · 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 two of 35 sampled residents. (Residents 39, 67) Findings include: Clinical record review revealed that Resident 39 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction, adult failure to thrive, and chronic pain in the left hand. Review of the care plan revealed that the resident required assistance with activities of daily living (ADLs) and had contractures of the left hand. Staff were to check fingernail length and trim and clean on bath days as needed, and fingernails were to be kept short. On November 25, 2024, at 12:59 p.m., the resident was observed in bed. His fingernails were long and dirty. There was a dark colored substance underneath the nails. The resident stated that his fingernails needed to be cut. On November 26, 2024, at 11:48 a.m., the resident was observed in bed. His fingernails remained long and dirty. Clinical record review revealed that…
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 before2024-11-27 · 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
Based on clinical record review, observation, 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 39, 67) Findings include: Clinical record review revealed that Resident 39 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction, adult failure to thrive, and chronic pain in the left hand. Review of the care plan date October 24, 2024, revealed that the resident was at risk for self-care deficit related to physical limitations and required extensive assistance from staff. There was a care plan intervention dated July 31, 2024, for staff to apply a left elbow extension splint during morning care and remove at night. On November 25, 2024, at 12:59 p.m., and November 26, 2024, at 11:48 a.m., the resident was observed in bed without the splint in place. There was no documentation to support that the resident had refused to wear the splint. Clinical record review revealed that Resident 67 had diagnoses that included…
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 · D2024-06-11 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
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 ensure each resident received timely treatment and services to maintain visual abilities for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included anxiety and hypertension (high blood pressure). Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had vision problems and needed corrective lenses. Review of the care plan revealed that Resident 1 was to use glasses everyday to watch television as an activity. On June 11, 2024, at 12:14 p.m., Resident 1 was observed in her room with the television on and not wearing glasses. In an interview at that time, she stated I have not had my glasses since March. Review of facility documentation revealed that a referral for eye care services was placed on March 13, 2024. Further review of facility documentation from April 22, 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.
- Potential for harm · Ecited before2023-11-02 · tag F0623 — patternProvide 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
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 the resident's representative(s) of transfer and the reasons for the move in writing for seven of 11 sampled residents who were transferred to the hospital. (Residents 37, 77, 90, 91, 137, 154, 159 ) Findings include: Review of the facility policy entitled, Discharge and Transfer, last reviewed November 11, 2022, revealed that the facility must notify the resident and resident representative in writing prior to the transfer or discharge in a language and manner they understand. Clinical record review revealed that Resident 37 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no evidence that the resident and the resident's representative was provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 77 was transferred and admitted to the hospital on [DATE], after 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.
- Potential for harm · E2023-11-02 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide a written notice of the facility's bed-hold policy to the resident or resident representative at the time of transfer for seven of 11 sampled residents who were transferred to the hospital. (Residents 37, 77, 90, 91, 137, 154, 159) Findings include: Clinical record review revealed that Resident 37 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident or resident's representatives were provided written information about the facility's bed-hold policy at the time of transfer. Clinical record review revealed that Resident 77 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident or resident's representatives were provided written information about the facility's bed-hold policy at the time of transfer. Clinical record review revealed that Resident 90…
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 · Ecited before2023-11-02 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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, observations, and resident and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for four of eight sampled residents with limitations in range of motion. (Residents 57, 91, 132, and 154) Findings include: Clinical record review revealed that Resident 57 had diagnoses that included dementia, osteoarthritis, and chronic pain syndrome. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident required extensive assistance from staff with Activities of Daily Living (ADL's). A review of the care plan revealed that the resident was at risk for loss of range of motion related to physical limitations. There was an intervention for staff to provide active range of motion to bilateral upper extremities with a.m.,and p.m.,care. Review of an occupational therapy Discharge summary dated [DATE], revealed that there was a recommendation for staff to provide a restorative nursing…
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 · E2023-11-02 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
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 non-pharmacological interventions to alleviate pain prior to the administration of pain mediation prescribed on an as needed basis for three of 35 sampled residents. (Residents 37, 108, 137) Findings include: Clinical record review revealed that Resident 37 had diagnoses that included peripheral vascular disease and spondylosis (arthritis of the spine). The resident had a physician's order for as needed pain medication, tramadol 50 milligrams (mg) to be administered every six hours as needed for pain. Review of the October 2023, Medication Administration Record (MAR) revealed that the resident received the tramadol 20 times without evidence to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed pain medication. Clinical record review revealed that Resident 108 had diagnoses that included chronic obstructive pulmonary disease and diabetes. The resident had a physician's order for as needed pain…
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 before2023-11-02 · 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 — the official record, unedited, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident representative of a change in condition for one of 35 sampled residents. (Resident 29) Findings include: Clinical record review revealed that Resident 29 had diagnoses that included schizoaffective disorder and dementia. Review of a nurse's noted dated October 23, 2023, revealed that Resident 29 tested positive for COVID-19 and a message was left for the resident representative to call the facility. Review of the clinical record revealed no further documentation that an attempt to notify the resident representative was made. There was no documented evidence that the resident's representative was notified of the change in condition. In an interview on November 2, 2023, at 12:15 p.m., the Director of Nursing confirmed that the resident's representative was not notified of the change in condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
- Potential for harm · Dcited before2023-11-02 · 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 review of facility policy and personnel file review, it was determined that the facility failed to obtain reference checks at the start of employment for two of five newly hired employees. (Employees 1 and 4) In addition, the facility failed to provide abuse training upon hire as per facililty policy for one of five employees. (Employee 2) Findings include: Review of the facility policy entitled Abuse Prohibition, last reviewed November 21, 2022, revealed that the facility prohibited abuse, mistreatment, neglect, misappropriation of resident/patient property and exploitation for all patients. The facility was to implement an abuse prohibition program by screening potential hires and training employees, both new employees and on-going training for all employees. Review of the personnel file for newly hired employee 1, who was hired on August 1, 2023, revealed that there was no documented evidence that reference checks were obtained through the screening process. Review of the personnel file for newly hired employee 4, who was hired on October 9, 2023, revealed that there 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.
- Potential for harm · D2023-11-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 that the Minimum Data Set (MDS) assessment was complete to accurately reflect the resident's status for four of 35 sampled residents. (Residents 57, 62, 68,104) Findings include: Clinical record review revealed that Sections C (Brief Interview for Mental Status), D (Mood assessment/interview) and E (Behaviors) of Resident 57's MDS assessment dated [DATE], was incomplete. Clinical record review revealed that Sections C (Brief Interview for Mental Status) and D (Mood assessment/interview) of Resident 62's MDS assessment dated [DATE], was incomplete. Clinical record review revealed that Section N (Medications) of Resident 68's MDS assessments dated August 18, 2023, and October 25, 2023, inaccurately indicated that the resident was on an anti-anxiety medication. There was no documented evidence or physician's orders to reflect that the resident was on an anti-anxiety medication during those assessment periods.…
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 before2023-11-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 a clinical record review, observation, and staff interview, it was determined that the facility failed to provide care in accordance with physician's orders for a percutaneous cholecystostomy (Catheter attached to the gall bladder, also called a chole) for one of 35 sampled residents. (Resident 50) Findings include: Clinical record review revealed Resident 50 was admitted to the facility on [DATE], with diagnoses that included acute cholecystitis (an inflammed gall bladder) with sepsis, acute respiratory failure with hypoxia (low oxygen levels in the tissues), and an infection of streptococcus anginosus. A physician order dated August 10, 2023, directed staff to record the amount of drainage from right chole tube every shift. Review of the treatment administration record for October 2023, revealed no evidence that the amount of drainage was recorded on the evening shifts for October 20, 21, 22, 26, 29, 27, 28, 29, 31 and November 1, 2023, as well as the night shifts on October 26, 27, 28, 2023.…
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 · D2023-11-02 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 facility policy review, clinical record review, and observation, it was determined that the facility failed to ensure aeseptic (free from germs that can cause infection or disease) wound treatments were completed in accordance with facility policy for one of 35 sampled residents. (Resident 132) Findings include: Review of the facility policy entitled, Procedure: Wound Dressings: Aseptic, last reviewed November 21, 2022, revealed that during the treatment of wounds, after removing the old dressing, staff was to remove gloves, perform hand hygiene, and apply new gloves. Clinical record review revealed that Resident 132 was admitted to the facility on [DATE], with diagnoses that included dementia and depression. On October 10, 2023, the physician ordered that Resident 132's right buttocks wound be cleansed with soap and water, irrigated with saline, packed with Aquacel AG or silver alginate (a silver impregnated dressing), and covered with a dressing. On October 30, 2023 at 1:50 p.m., Licensed Practical…
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 before2023-09-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 clinical record review and staff interview, it was determined that the facility failed to implement physician orders for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure (CHF), atrial fibrillation, hypertensive heart disease, and presence of a heart assistance device (cardiac implanted defibrillator). The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance with hygiene and bed mobility. A review of the care plan revealed that the resident had cardiac disease related to the CHF, atrial fibrillation and use of an Left Ventricular Assist Device (LVAD). A LVAD is a surgically implanted device which helps the left ventricular main pumping chamber of the heart pump blood to the rest of the body. Review of current physician orders revealed that licensed staff was to check the settings on the LVAD and document the completion…
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 · C2025-09-05 · tag F0628 — widespreadProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for eight of nine residents who were transferred out of the facility. (Residents 1, 3, 5, 9, 10, 12, 18, 66) Findings include: Clinical record review revealed that Resident 1 was transferred to the hospital on July 27, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 3 was transferred to the hospital on August 7, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 5 was transferred to the hospital on July 31, 2025, after a change in condition.…
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 · Bcited before2024-07-26 · tag F0623 — patternProvide 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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the residents and the residents' representatives of the transfers and the reasons for the moves in writing upon transfer from the facility for three of four sampled residents who were transferred to the hospital. (Residents 1, 2, 3) Findings include: Review of the facility policy entitled Discharge and Transfer, last reviewed March 14, 2024, indicated that the facility was to notify the resident and resident representative in writing prior to the transfer. Transfer and discharge included the movement of a resident to a bed outside of the certified Center. Clinical record review revealed that Resident 1 had diagnoses that included schizoaffective disorder and epilepsy. On June 29, 2024, the resident was transferred to the hospital for a change in condition. Clinical record review revealed that Resident 2 had diagnoses that included heart disease. On May 31, 2024, the resident was transferred and admitted to the hospital for a change in condition.…
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 · C2023-11-02 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 and resident interview, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on four of four nursing units. (Medbridge, Unit 2, Unit 3, Unit 4) Findings include: Observation of the Medbridge Unit on October 30, 2023, at various times, revealed a hole in the wall by the door and stained ceiling tiles in the resident dining room. There was peeling wallpaper in the bathroom of room [ROOM NUMBER], peeling wallpaper and a black substance on the floor of the bathroom in room [ROOM NUMBER], and a black substance on the floor and a broken soap dispenser in the bathroom of room [ROOM NUMBER]. Observations of Unit 2 on October 30 and 31, 2023, at various times, revealed dead bugs on the floor by the window in room [ROOM NUMBER], stained ceiling tiles by the windows in rooms [ROOM NUMBERS], cracked tiles in the hallway across from the elevator, a cracked red outlet cover outside room [ROOM NUMBER], and a towel covering the wall vent in room…
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 · C2023-11-02 · tag F0814 — failed to dispose of garbage properly — widespreadDispose 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 properly contain refuse. Findings include: Observation on October 30, 2023, at 10:38 a.m., revealed the compactor for garbage was located at the rear of the building. At this time, there was garbage and debris that included plastic bags and soiled gloves on the ground around the compactor area.
“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
$27,378 in federal fines across 1 penalty.
- $27,378 — penalty dated 2026-04-29
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
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 | 3 of 5 | 3.5 | -0.5 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 11/14/2022 |
| FC-GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| GENESIS HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| GHC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| SUN HEALTHCARE GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/14/2022 |
| WHITMAN, ARNOLD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2020 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 11/14/2022 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| AVERSA, THADDEUS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/12/2025 |
| CALLAZO, NANCY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/12/2025 |
CMS files one row per role, so the 17 rows in the source record cover these 15 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 83% 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 $8.4M 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. 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 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 395429. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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.