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Sunset Ridge Rehabilitation And Nursing Center

3298 Ridge Road, Bloomsburg, PA 17815 · For profit - Corporation · 66 certified beds · (570) 784-6688 Medicare & Medicaid certified

Call the home — (570) 784-6688 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 2024Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation$100,369 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • 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 $100,369 in federal fines (most recent 2024-04-25)

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3151 Columbia Blvd · (570) 245-0093 · Call to confirm hours
Pharmacy
1000 Market St · (570) 784-9582 · Call to confirm hours
Grocery
1009 Old Berwick Rd · (570) 762-7805 · Call to confirm hours
Park
10 Park Ave · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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 improved from 2 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.8%16.8%15.4%better
Long-stay residents who lose too much weight3.1%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms13.6%10.8%6.5%worse
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened3.8%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.9%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers2.2%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control25.3%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table5.9%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine98.0%68.7%79.4%better
Short-stay residents rehospitalized after admission28.8%22.5%22.6%worse
Short-stay residents with an outpatient ER visit9.2%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days3.561.621.67worse
Long-stay outpatient ER visits per 1,000 resident days2.041.181.80worse

§ 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.

53.0% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.0%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
46.1%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 46.1% 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 52 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.0%CMS range 40.6–63.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.1–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge46.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge32.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge95.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.5–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.76
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.70
Total nurse hours/ resident / day
0.50
RN hoursweekends
32.8%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 66 beds and averages 64.6 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.26 hrs/resident/day on weekends vs 3.88 on weekdays — 16% thinner on weekends. RN hours go from 0.86 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below 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

10
deficiencies at the latest standard inspection (2026-01-23)
11
at the previous standard inspection (2025-03-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.

  • Actual harm · G2024-04-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that two residents (Resident 45 and 42) were free from sexual abuse perpetrated by one resident (Resident 6) out of 19 sampled residents. Findings include: A review of the current facility policy entitled Abuse Prevention Program, last reviewed by the facility January 2024, revealed that the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. A review of the facility policy entitled Identifying Types of Abuse last reviewed January 2024, revealed sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate sexual touching of any kind especially to the breasts or perineal area. Further it is indicated that sexual contact is non-consensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. A review…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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

    Based on observations, a review of resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide a comfortable and homelike environment for residents, specifically regarding maintaining comfortable ambient temperatures in common areas for four out of four residents interviewed during a group interview (Residents 25, 60, 69, and 76).Findings include: A review of resident council meeting minutes dated December 9, 2025, revealed that residents in attendance raised complaints the dining room was cold. During a resident group interview on January 22, 2026, at 10:00 AM Residents 25, 60, 69, and 76 indicated that they have a concern about the cold temperatures in the facility's dining room. The residents explained that the room is used for dining and activities throughout the day and into the evening. During the group interview Resident 69 indicated that he has been raising concerns about how cold it feels in the dining room for weeks, but no one has addressed the issue. He explained that he was playing bingo in the room yesterday,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-23 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, a review of select facility policies, and staff interviews, it was determined that the facility failed to provide person-centered care and failed to follow professional standards of practice for diabetes management for one of 21 sampled residents (Resident 2). Findings include: A review of the facility policy titled Diabetes Clinical Protocol, last reviewed by the facility on January 5, 2026, indicated it is the policy of the facility that the physician will order appropriate laboratory blood tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results. Further review revealed the resident receiving insulin who is well controlled should monitor blood glucose levels twice a day if on insulin (for example, before breakfast and lunch, and as necessary) and monitor three to four times a day if on intensive insulin therapy or sliding scale insulin. Adjust monitoring frequency depending on glucose control and resident preference. A review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-23 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, a review of the facility's planned menus, a review of resident group meeting minutes, and resident and staff interviews, it was determined that the facility failed to accommodate individual food preferences, to the extent possible, to increase resident satisfaction with meals for residents, which included four out of the 21 residents sampled (Residents 4, 25, 33, and 69), and as expressed by four out of four residents during a resident group interview (Residents 25, 60, 69, and 76). Findings include: A review of resident group meeting minutes dated November 18, 2025, revealed residents in attendance raised concerns that they would like more soup added to the facility menu. A review of a Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 19, 2025, revealed that Resident 4 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 review of clinical records, grievances filed with the facility, facility documentation, and staff and resident interviews, it was determined the facility failed to ensure a resident's right to privacy and failed to prevent intrusion by another resident (Resident 29) during personal care for one out of 21 residents sampled (Resident 37).Findings include:A clinical record review revealed Resident 37 was admitted to the facility on [DATE], with diagnoses that include muscular dystrophy (a group of diseases characterized by progressive weakness and degeneration of skeletal muscles that control movement). A review of an annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 30, 2025, revealed that Resident 37 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of employee personnel files, select facility policy, and staff interviews, it was determined the facility failed to fully implement its abuse prohibition procedures and ensure a criminal history record check was requested or obtained prior to employment for one out of five employees reviewed (Employee 2). Findings include:A review of the facility policy titled Abuse Prevention Program, last reviewed by the facility on January 5, 2026, revealed it is the facility policy to protect residents from abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Administration will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. A review of personnel files revealed Employee 2, Licensed Practical Nurse (LPN), start date with the facility was October…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 review of clinical records and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan that reflected the resident's current medical status and required interventions for one of one sampled residents (Resident 7). Findings include: A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and diagnosed with a subdural hemorrhage (brain bleed) after sustaining a fall on September 5, 2025, and diagnosed with a deep vein thrombosis (a blood clot) in the left leg on November 17, 2025. A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 7 dated December 28, 2025, revealed the resident was severely cognitively impaired with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, observation, and resident and staff interview it was determined the facility failed to ensure the resident environment was free from potential accident hazards for one of 21 sampled residents (Resident 15).Findings include:A review of a facility policy titled 'Storage of Medications', last reviewed on January 5, 2026, indicated the facility will ensure all medications will be stored in the pharmacy and/ or medication rooms according to manufacturer's recommendations. The general guidelines in the policy interpretation direct staff that all drugs and biologicals are to be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control. A clinical record review revealed Resident 15 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure (condition in which one or both of the kidneys no longer work on its own). According to the Brief Interview 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 the attending physician documented a clinical rationale for declining a consultant pharmacist's recommendation to reduce a psychoactive medication for one of five sampled residents reviewed for unnecessary medications (Resident 66).Findings include:A review of the clinical record revealed that Resident 66 was admitted to the facility on [DATE], with diagnoses that included diastolic congestive heart failure (a long-term condition in which the heart cannot pump blood efficiently to meet the body's needs), dysphagia, oropharyngeal phase (difficulty swallowing), and chronic respiratory failure with hypoxia (a condition in which the body does not receive enough oxygen). A review of a consultation report completed by the facility's consultant pharmacist dated December 12, 2025, revealed Resident 66 was receiving Duloxetine Hydrochloride 30 mg one capsule daily, an antidepressant in the class of Serotonin 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-23 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary medications and failed to ensure nonpharmacological interventions were implemented prior to the initiation of an anticonvulsant medication used as a psychotropic medication (a drug that affects brain activity related to thinking, emotions, and behavior) for the treatment of a mood disorder (a category of mental illnesses in which the primary problem affects a person's emotional state) for one of five residents reviewed for unnecessary medications (Resident 52).Findings included: A review of the facility Psychoactive Medication Use Policy last reviewed January 5, 2026, indicated psychoactive medications may be used when necessary to treat specific conditions or diagnoses for which they are clinically indicated and effective. The psychoactive medication regimen will be regularly reviewed by the physician, and gradual dose…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication storage rooms (East wing medication room).Findings include: A review of the facility policy titled Administering Medications, last reviewed by the facility January 5, 2026, indicated that when opening a multi-dose container, (medication vial that can be punctured with a needle multiple times for more than one dose of the same medication) the date opened for use will be recorded on the container. A review of the facility policy titled Storage of Medications, last reviewed by the facility January 5, 2026, indicated that it is the policy of the facility to ensure all medications housed on premises will be stored in medication rooms according to the manufacturer's recommendations and sufficiently to ensure proper sanitation, temperature, light, moisture control, segregation, and security. An observation of the East wing medication room on January 22, 2026, at 8:37 AM, in 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · F2025-03-13 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 review of the facility's planned 4-week menu cycle and menu extensions, resident interviews, and staff interviews, it was determined the facility failed to ensure the planned menu was sufficiently reviewed and updated to ensure that the menu offered variety and avoid repetitive meal selections. Findings included: During a Resident Council meeting conducted on March 12, 2025, at 10:35 AM, with Residents 40, 45, 48, and 264, concerns were raised regarding the lack of variety in the facility's menu. Resident 48 reported that the menu was repetitive, and they get the same meats for days in a row and that the meals offered on the facility's always available menu were the same items rotated throughout the standard regular menu. Residents 40, 45, and 264 also confirmed that meals, especially meats, were frequently repeated over consecutive days. Resident 264, the elected Resident Council President, stated that concerns had been raised in food committee meetings with the Certified Dietary Manager (CDM) but were…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, increasing the risk of contamination and foodborne illness in the dietary department Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During an initial tour of the dietary department on March 11, 2025, at 9:10 AM, conducted with the Food Service Director (FSD) and Employee 1, a food service worker (FSW), 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility policies, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program. Findings included: A review of a select facility policy entitled, Infection Prevention and Control Program last reviewed by the facility January 2025 revealed the facility must establish an infection prevention and control program under which it identifies, investigates, controls, and prevents infections in the facility. Further it is indicated the objectives of the infection control policies and procedures are to prevent, detect, investigate, and control infections in the facility. A review of facility policy entitled Surveillance for Infections last reviewed January 2025 revealed for residents with infections that meet the criteria for definition of infection the facility will collect the following: A. Identifying information including the residents name, age, room number, unit, an attending physician B. Diagnoses C. admission date, date of onset of infection…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-13 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    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 review of clinical records and staff interview it was determined the facility failed to maintain a system to effectively monitor antibiotic usage in accordance with its antibiotic stewardship program for one of 17 sampled residents (Resident 1). Findings include: A review of select facility policy entitled, Antibiotic Stewardship last reviewed January 2025 revealed antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program. The purpose of the antibiotic stewardship program is to monitor the use of antibiotics. A review of select facility policy entitled, Antibiotic Stewardship Orders for Antibiotics Last review January 2025 revealed appropriate indications for use of antibiotics stated that appropriate indications for antibiotic use include meeting the clinical definition of active infection or suspected sepsis and confirming pathogen susceptibility based on culture and sensitivity results. A review of select facility policy…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, facility investigative reports, and staff interviews, it was determined the facility failed to implement adequate safety measures, including sufficient staff supervision, for a resident identified as at high risk for falls resulting in multiple recurrent falls for one resident (Resident 50) out of 17 sampled Findings include: A review of Resident 50 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), abnormalities of gait and mobility (refer to any unusual or unexpected patterns of movement or changes in the way an individual walks or moves), repeated falls, hypertensive heart disease (refers to heart conditions caused by high blood pressure), and urinary tract infection (UTI - is an infection in the bladder, kidneys, ureters, or urethra). The resident's person-centered fall care plan initiated on January 13, 2023, identified Resident 50 was at risk for falls due to frequent falls and impulsiveness due to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0697 — failed to manage pain — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 60) and failed to implement interventions to alleviate pain for one resident (Resident 15) out of 17 residents reviewed. Findings include: A review of the clinical record revealed that Resident 60 was admitted to the facility on [DATE], with diagnoses to include multiple rib fractures with routine healing. A review of Resident 60's clinical record revealed physician orders for as-needed (PRN) pain medication included: Oxycodone HCL 5 mg (narcotic pain medication), one tablet by mouth every four hours as needed for pain rated 5 to 7 (scale used to rate pain, with 0 being no pain and 10 being severe pain), initiated on January 13, 2025, and ending January 26, 2025. Oxycodone HCL 5 mg, two tablets by mouth every four hours as needed for pain rated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 review of clinical records and staff interview, it was determined that the facility failed to develop and implement an effective individualized person-centered plan to address and manage the dementia-related behavioral symptoms of one out of 17 residents reviewed (Resident 10). Findings include: A review of Resident 10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The resident exhibited recurrent episodes of increased agitation, aggressive and argumentative behaviors, verbal threats toward staff and residents, and delusional ideation, including believing another resident was her daughter and that staff had taken her daughter. A review of a progress note dated August 25, 2024, at 8:37 PM revealed the resident became increasingly agitated making threats of harm, stating if she gets killed, she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of controlled drugs in sufficient detail to enable accurate accounting of controlled substances when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 62). Findings include: Review of the facility's Discharge Medications policy last reviewed by the facility on January 25, 2025, indicated controlled substances shall not be released upon discharge of the resident unless permitted by current state law governing the release of controlled substances and as authorized (in writing) by the resident's Attending Physician. The nurse will reconcile pre-discharge medications with the resident's post discharge medications and the medication reconciliation will be documented. The nurse shall complete the medication disposition record…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 17 residents sampled (Residents 1). Findings included: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include history of malignant neoplasm (cancer) of the bladder and dementia (a decline in memory, thinking, and other cognitive abilities, significantly impacting daily life). A nursing progress note dated October 16, 2024, at 8:23 AM indicated the resident's white blood count (WBC) was elevated at 15.48 ul (4.000 ul to 1100 ul normal), but the resident did not exhibit any other signs or symptoms of infection at that time. The physician was notified, and an order was obtained for a Urinalysis with Culture and Sensitivity (UA C&S a laboratory test used to detect and identify bacteria or fungi in urine, A urine culture is a method to grow and identify…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 clinical records, facility investigative reports, and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, in accordance with professional standards of practice for two of 17 sampled residents (Resident 8 and 44). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 a review of clinical records and staff interviews it was determined the facility failed to ensure coordination of care and services between the facility and the Hospice Agency for one resident out of 17 sampled residents (Resident 1). Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include history of malignant neoplasm (cancer) of the bladder and dementia (a decline in memory, thinking, and other cognitive abilities, significantly impacting daily life). A review of physician's orders dated February 18, 2025, revealed the resident was admitted into hospice services. A review of the resident's care plan, initially dated January 27, 2024, revealed that the care plan failed to reflect coordination of services between the facility and the hospice agency. Specifically, the care plan lacked documented evidence of collaboration in addressing the resident's daily care needs and specific care and services related to 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-25 · tag F0609 — failed to report abuse allegations — pattern
    Timely 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 a review of select facility policy and clinical records, and staff interviews it was determined that the facility failed to timely report sexual abuse of two residents (Resident 45 and 42) out of 19 residents sampled to the State Survey Agency. Findings include: A review of facility policy entitled Investigation of Allegations of Abuse, Neglect, or Misappropriation of Resident Property last reviewed January 2024 revealed within 24 hours all incidents of abuse will be reported electronically to the [NAME] Field Office Pennsylvania Department of Health. Alleged or proven incidents of abuse involving staff, resident, or other healthcare workers will be reported on a PB22 to the [NAME] Field office of the Pennsylvania Department of Health (the state survey agency) within five working days of the incident. The police are to be called immediately in cases of sexual abuse. A review of clinical record revealed that Resident 45 was admitted to the facility on [DATE], with diagnoses which included dementia (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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-25 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    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 review of clinical records and select facility policy and staff interviews it was determined that the facility failed to conduct a timely and thorough investigation into sexual abuse of two residents out of 19 sampled (Resident 45 and 42). Findings included: A review of facility policy entitled Investigation of Allegations of Abuse, Neglect, or Misappropriation of Resident Property last reviewed January 2024 revealed when notified of abuse, the Registered Nurse Supervisor or Department Head shall immediately initiate an investigation which includes the removal of the alleged perpetrator and notify the administrator/designee. Abuse situations include but are not limited to sexual abuse. When an allegation of sexual abuse is made or suspected the following steps should be implemented. Do not display alarm or disbelief. Reassure the abuse is not their fault. Arrange for medical attention. Document and preserve any evidence. Do not touch or disturb the scene. Further it is indicated written statements…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-25 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and/or implement a person-centered comprehensive care plan for five residents out of 19 sampled (Residents 2, 6, 60, 61 and 14). Findings include: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included constipation. A review of Resident 2's current physician orders revealed the following orders: Senna-S tablet 8.6-50mg give one tablet by mouth for chronic constipation and chronic ileus (Inability of the intestine to contract normally and move waste out of the body) Miralax 17 grams by mouth every 12 hours for constipation and chronic ileus. Milk of Magnesia 400 mg/5ml give 30 mls by mouth as needed for constipation. Administer if no BM by the third day/9 shifts. Dulcolax Suppository insert on suppository rectally as needed for constipation for no bowel movement with 24 hours after of the administration of Milk of Magnesia. Fleet…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-25 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and clinical records, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed and professional nurses promptly assessed residents following instances of sexual abuse for two residents (Residents 45 and 42) and failed to follow physician's orders for administration of a bowel protocol to promote bowel activity for two residents (Resident 2 and 61) out of 19 sampled. Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-25 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility scheduled meal times and select facility policy, and resident and staff interviews the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including seven residents of 19 sampled (Residents 56, 27, 62, 6, 26, 21, and 28). Findings include: Review of the facility's Snacks Policy last reviewed January 2024, indicated that it is the facility policy to provide bulk snacks and beverages to each resident care area for availability upon request, snacks as identified in the individual plan of care, and bedtime (HS-hour of sleep) snacks to all residents. Review of the facility's scheduled (not exact times may fluctuate +/- 15 minutes) meal times revealed 14 hours between the evening meal and the next day's breakfast meal. During an interview on April 23, 2024, at 11:30 AM Resident 56 stated that he would like milk or coffee before bed at times, and that evening snacks are not always offered. During a group…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-25 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for three of 19 sampled residents (Resident 6, 45, 42). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records and select facility policy, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent spread of infection for three of 19 sampled residents (Residents 56, 1, and 59) Findings include: According to the Centers for Disease Control (CDC) Enhanced Barrier Precautions (EBP) guidance focus on gown and glove use and not other important infection control measures for prevention of multi-drug resistant organisms (MDRO). EBP are recommended for residents with any of the following: infection or colonization with a MDRO, a wound, or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Review of the facility Enhanced Barrier Precautions last reviewed/revised March 2024 indicated that to minimize the transmission of germs transferring from residents to staff hands and clothing, staff will wear a gown and gloves when providing care to residents that require significant…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to timely notify the physician and the resident's representative of an incident with the potential to require physician intervention and cause psychosocial harm to one resident out of 19 sampled (Resident 45). Findings include: A review of facility policy entitled Notification of Changes last reviewed January 2024, revealed that it is the policy of the facility that a change in a resident's condition are to be shared with the resident's representative and reported to the attending physician. A review of clinical record revealed that Resident 45 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of clinical record revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interviews it was determined that the facility failed to timely train one agency employees out of eight employees reviewed on the facility's abuse prohibition policy and procedures. Findings include: An interview with Employee 1 Agency NA (nurse aide) on April 23, 2024, at approximately 1:00 PM revealed the employee stated it was her first day working in the facility and she was not given an orientation or trained on the facility's abuse policy prior to working on the nursing unit with the residents. A review of the resident's employee file revealed no documented evidence was provided that the facility provided abuse training on the facility's abuse policy prior to working on the nursing units with residents. An interview with Nursing Home Administrator on April 25, 2024, at approximately 1:45 PM confirmed there was no documentation that Employee 1 was trained on the facility's abuse prohibition policy and procedures prior to assuming their job duties. 28 Pa. Code 201.20(b) Staff development 28 Pa Code 201.18 (e)(1) Management

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-04-25 · tag F0623 — pattern
    Provide 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding facility initiated transfers to the hospital was provided to the residents and their representatives for five of 19 residents sampled (Resident 27, 7, 59, 66, and 29) Findings include: A review of Resident 27's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. A review of Resident 7's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. A review of Resident 59's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. The resident was again transferred to the hospital [DATE] and returned to the facility on [DATE]. A review of Resident 66's clinical record revealed that the resident was transferred to the hospital on February 24, 2024, and expired at the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-04-25 · tag F0625 — pattern
    Notify 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 a review of clinical records and staff interview it was determined that the facility failed to provide residents or their representatives with written information of the facility's bed hold policy upon transfer to the hospital of five residents out of 19 residents sampled (Resident 27, 7, 59, 66, and 29). Findings include: A review of Resident 27's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. A review of Resident 7's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. A review of Resident 59's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. The resident was again transferred to the hospital [DATE] and returned to the facility on [DATE]. A review of Resident 66's clinical record revealed that the resident was transferred to the hospital on February 24, 2024, and expired at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$100,369 in federal fines across 1 penalty.

  • $100,369 — penalty dated 2024-04-25

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 ALLAIRE HEALTH SERVICES — 20 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 →

RatingThis homeChain avg
Overall 3 of 52.6+0.4 vs chain
Health inspection 3 of 52.2+0.8 vs chain
Staffing 4 of 53.1+0.9 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 19 homes this chain runs (chain average 2.6★, per CMS)

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 / managerTypeRoleSince
KURLAND, NAOMIIndividualDIRECT OWNERSHIP INTERESTsince 04/01/2024
CLARITY, JASONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2024
FLICK, TRENTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2024
KURLAND, BENJAMINIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/08/2025
GV CONSULTINGOrganizationADP OF THE SNFsince 01/08/2025

CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$6.4M
Net patient revenuemost recent cost report
-36.5%
Operating marginrevenue minus expenses
$1.1M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 6%Other / private 16%

About 79% 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 $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$389per resident / day
operating cost
$11,823per month
≈ monthly operating cost
$285per day
avg. revenue, all payers

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

What families pay in PA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395953. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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.

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