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Naamans Creek Country Manor

1194 Naamans Creek Road, Boothwyn, PA 19061 · Non profit - Corporation · 90 certified beds · (610) 558-7840 Medicare & Medicaid certified

Call the home — (610) 558-7840 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited May 2025
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3565 Philadelphia Pike · (302) 320-4110 · Call to confirm hours
Pharmacy
Walgreens0.5 mi
2608 Naamans Creek Rd · (484) 490-1030 · Call to confirm hours
Grocery
401 Naamans Rd 3 · (302) 798-5042 · Call to confirm hours
Park
100 Darley Rd · (302) 395-5606 · 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 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.6%16.8%15.4%worse
Long-stay residents who lose too much weight7.2%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection2.0%1.5%2.0%typical
Long-stay residents with depressive symptoms0.5%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury5.5%3.1%3.3%worse
Long-stay residents whose ability to walk worsened27.9%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication10.7%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine82.3%93.5%95.3%worse
Long-stay residents with pressure ulcers5.5%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control25.6%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table5.4%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine51.4%68.7%79.4%worse
Short-stay residents rehospitalized after admission27.7%22.5%22.6%worse
Short-stay residents with an outpatient ER visit8.2%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.381.621.67worse
Long-stay outpatient ER visits per 1,000 resident days1.061.181.80better

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

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

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

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

60.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 227 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.3%U.S. median 51.5%
Got home and stayed home
14.4%U.S. median 10.7%
Went back to hospital
36.4%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 36.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 143 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF60.3%CMS range 53.3–66.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.4%CMS range 11.4–17.610.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge36.4%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 discharge43.4%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 discharge38.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 setting94.3%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%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 worsened5.6%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 hospitalization7.7%CMS range 4.8–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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
1.08
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.94
Total nurse hours/ resident / day
0.58
RN hoursweekends
49.5%
Total nursing turnover
21.4%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 72.7 residents a day — about 81% occupied, or roughly 17 beds typically open. It usually has some room. 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 3.94 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 2.10 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 3.66 hrs/resident/day on weekends vs 4.05 on weekdays — 9% thinner on weekends. RN hours go from 0.83 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2026-06-26)
5
at the previous standard inspection (2025-05-02)

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.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

  • Potential for harm · Ecited before2026-06-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 — the official record, unedited, may be distressing

    Based upon observation and interview, it was determined that the facility failed to ensure appropriate storage, labeling, and dating was completed for pre-prepared food items in the refrigerator. Observation of the facility refrigerator located in the kitchen on June 24, 2026, at 12:48 p.m. revealed a clear plastic container filled with prepared chicken salad sandwiches. The container was covered with a loose sheet of parchment paper, held in place with a plastic bucket of chicken salad. Interview with the kitchen manager on June 24, 2026, at 12:50 p.m. confirmed that the prepared sandwiches were not properly labeled, dated, or covered. The facility failed to ensure that food was stored properly, labeled, and dated according to professional standards. 28 Pa. Code 201.18(b)(1)

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-06-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for one of one resident (Residents R27). Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS - a periodic assessment of care needs) dated May 2, 2026, with the diagnoses of aphasia (language disorder that affects communication), vascular dementia, unspecified severity, with agitation (a neurocognitive disorder caused by damage to the brain from reduced or interrupted blood flow due to cerebrovascular disease, resulting in impaired memory, thinking, judgment, and the ability to perform daily activities), muscle weakness, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-06-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of eight residents reviewed for nutrition (Resident R9). Review of facility policy Weighing of Residents .If the resident exhibits a weight change of 5 lbs. from the previous weight (weights over 100#) in the monthly weight report, the resident shall be re-weighed within 24 hours and the re-weight shall be recorded, The licensed nurse or designee should then strike out the previous weight to identify that a re-weight was obtained and verified. Review of Resident R9's clinical record revealed recorded weights of:February 4, 2026: 191.2 lbsFebruary 5, 2026: 191.2 lbsMarch 13, 2026: 168.2 lbsApril 2, 2026: 240.0 lbsApril 4, 2026: 191.0 lbsFurther review of Resident R9's clinical record revealed a dietary note dated March 19, 2026, indicating the resident's weight. Further review of the same dietary note revealed a recommendation of reweight requested for the March 13, 2026, weight.Interview with Registered Dietitian on June 25, 2026, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-04-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 — the official record, unedited, may be distressing

    Based on observations and staff interview, it was determined that the facility failed to ensure that food stored in the walk-in freezer was properly stored to prevent contamination and ensure safe storage in accordance with professional standards for food service safety. (Main Kitchen) Findings include: Observations in the kitchen on April 13, 2026, at 10:10 a.m. in the presence of the Assistant Food Service Director (AFSD) revealed a large accumulation of ice on the ceiling of the freezer with some ice extending on to the boxes on the top shelf labelled; pancakes; Portico seafood and Vegetable blend. Interview with AFSD on April 13, 2026, at 10:15am confirmed that the ice build up should not be there The above findings were conveyed with the Nursing Home Administrator (NHA) on April 13, 2026, at 11:30am and confirmed the above findings. 28 Pa. Code 211.6(f) Dietary services.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-02 · 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 observations, review of facility policies, and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety for two of two nursing units (First Floor and Second Floor nursing units). Findings include: Review of the facility policy, Dry Food Storage dated May 30, 2025, revealed, dry food storage is necessary for foods that do not require refrigeration or freezing and requires proper guidelines. All food items must be dated, labeled and sealed. Rotate products to ensure that the oldest inventory is used first. Observation on April 29, 2025, at 9:45 a.m. of the second-floor kitchen dry food storage area revealed expired used by dates for multiple loaves of bread and packages of buns. This included, 1 package of hot dog buns use by dated April 8, 2025, 1 loaf of wheat bread use by dated April 27, 2025, 1 loaf of raisin bread use by dated April 25, 2025, 5 packages of hamburger buns use by dated April 26, 2025, of which 2 packages revealed black and green spots on the buns, and 9 loaves of rye…

    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 before2025-05-02 · 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 the facility's policy, clinical records review, and staff interview, it was determined the facility failed to ensure physician's orders were followed for three of the 18 residents reviewed (Residents 13, 14, and 66). Findings include: A review of the facility's policy titled Weighing of Residents, undated revealed that residents requiring daily weights due to clinical conditions warranting strict monitoring will be weighed in the same procedures as stated above. Documentation of the daily weight will be recorded in the electronic medical record (EMR). If the resident experiences a weight gain of three (3) pounds in a 24-hour period or a weight gain of greater than five (5) pounds in a week, the licensed nurse will notify the physician. Clinical records review revealed Resident 13 was admitted to the facility on [DATE], with a diagnosis of Congestive Heart Failure (CHF weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 13's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-02 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility's policy, clinical records review and staff interviews, it was determine that the facility failed to appropriately monitor the weights and timely address identified significant weight changes for three of 18 Residents reviewed (Resident 63, 66 and 175). Findings include: A review of the facility's policy titled Weighing of Residents, undated, revealed that the facility must monitor the resident's weight to detect significant weight loss or gain to ensure that the resident maintains acceptable parameters of nutritional status. The same policy revealed that upon admission and readmission, the resident is weighed weekly for one month. An assigned licensed nurse or designee should review resident weights after they are entered or recorded. If the resident exhibits a change of five (5) pounds from the previous month's weight report and three (3) pounds from the previous weight report, the resident shall be reweighed within 24 hours and the re-weight shall be recorded. If the weight change falls into the significant category- 5% in one month or 10% in six…

    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 · D2025-05-02 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records and staff interview it was determined that the facility failed to ensure that one resident out of 24 sampled was free of chemical restraints (Resident 63). Findings include: A review of Resident 63's clinical record revealed admission to the facility on January 24, 2025, with diagnoses to include cerebral infraction (pathologic process that results in an area of necrotic tissue in the brain), cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). An admission Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated January 24, 2025, indicated that the resident is moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8-12 represents moderate cognitive impairment). A review of resident 63's clinical record…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · 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

    Based on clinical record review and staff interviews, it was determined that the pharmacy failed to ensure medication for wound care was available for one of the four residents reviewed (Resident 175). Findings include: A review of Resident 175's physician order dated April 29, 2025, revealed an order for Santyl (A topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) ointment, apply nickel thick layer to the sacrum (The triangular bone just below the lumbar vertebrae) wound bed after cleansing with normal saline solution, cover with foam dressing once a day and as needed. May use Medihoney (A dressing that aids and support debridement and a moist wound healing environment in acute and chronic wounds and burns.) until Santyl arrives. An observation of the wound care treatment conducted on May 1, 2025, at 9:45 a.m., revealed that Medihoney treatment was used for the sacral wound instead of the Santyl. An interview with licensed nurse Employee E4 conducted on May 1, 2025, at 9:50 a.m., revealed that the facility was still…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-24 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions and failed to prevent cross-contamination for one of 12 resident observed during lunch (Resident R7). Findings include: Observations conducted on September 24, 2024 at 12:15 p.m. in the main dining area on the second floor during the lunch meal tray line, revealed Licensed (LPN) Employee E1 removed R7's tray from the tray cart which revealed a soiled cloth towel on the tray touching the plate containing R7's meal. Further observation on September 24, 2024 revealed licensed Employee E1 returned from the kitchen at 12:18 p.m. with a new tray and meal for R7. Interview conducted with the Dietary Manager, on September 24, 2024, at 12:45 p.m. confirmed the soiled towel should not have been on R7's tray and reported that it was an accident. Interview conducted with the Director of Nursing (DON) on September 24, 2024, at 12:55 p.m. confirmed that all resident trays should be free of soiled cloth towels. 28 Pa. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 5 citations
  • Potential for harm · Ecited before2024-05-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 a review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain dish machine water temperatures by manufacturer recommendations for food service safety in the main kitchen. Findings include: A review of the facility's policy titled Machine Ware Washing undated, revealed that dining services will properly clean and sanitize all service ware to destroy foodborne pathogens. The same policy revealed that the staff will monitor/document water temperatures routinely in the Mechanical ware washer water temperature log. Monitoring schedule: at least one time every meal (mid-morning - breakfast clean-up, mid-afternoon - lunch clean-up, and evening - supper clean-up). Standard temperature = Wash = > 150 F. Final Rinse = > 180 F. A kitchen tour was conducted on May 14, 2024, at 9:34 a.m., with the presence of the Food Director Employee E4. An observation of the dish machine was conducted and revealed drinking cups and plates were being washed. An observation of the Wash temperature gauge revealed a temperature of 140F. 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 · D2024-05-17 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — the official record, unedited, may be distressing

    Based upon observation, it was determined the facility failed to ensure residents were treated with dignity and failed to ensure private health information was secure for one of 24 residents observed (Resident 56). Findings include: Observation of Resident 56's room on May 16, 2024, at 11:00 a.m. revealed the presence of two white boards. One board was located on the wall next to Resident 56's bed and the other board was located on the wall directly below Resident 56's television. Further observation of these white boards revealed the following information Dietary restrictions - Mildly thick/nectar thick liquids only. No ice, room temp liquids via teaspoon. Further observation of Resident 56's room revealed a paper sign located above the head of Resident 56's bed. The sign indicated no straws. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on May 17, 2024, at 10:00 a.m. 28 Pa. Code 201.18(b)(2) Management

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical records review and staff interview, it was determined that the facility failed to monitor a fluid restriction order for one of the 18 residents reviewed (Resident 235). Findings include: Review of Resident 235's diagnosis list includes Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Kidney Failure, and Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). Review of Resident 235's physician's order dated May 9, 2024, revealed an order for 2000 ml (milliliter) fluid restriction, and heart-healthy modification. The clinical records review failed to reveal evidence that Resident 235's fluid intake was monitored to ensure the 2000 ml fluid restriction ordered by the physician was followed. Interview was conducted with the Director of Nursing on May 17, 2024, at 11:00 a.m. The Director of Nursing confirmed that nursing does not have documented evidence that Resident 235 ' s 2000 ml fluid restriction…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records review and staff interview, it was determined that the facility failed to ensure skin impairment identified upon admission was comprehensively assessed for two of the six residents reviewed (Resident 57 and 235). Findings include: Review of the facility's policy titled Pressure Injury Management Program Evaluating Risk, Prevention, Support Planning, Treatment, and Monitoring, last reviewed in October 2021, revealed that residents admitted with pressure ulcers receive the care and services necessary to promote healing. A review of the same policy revealed that an evaluation of the pressure ulcer should be documented. At a minimum, documentation must include the date observed and the following: location, size, exudate if present, pain, wound bed, and description of wound edges and surrounding tissue as appropriate. Review of Resident 57's clinical records revealed Resident 57 was admitted to the facility on [DATE], with a diagnosis of Pneumonia. Review of Resident 57's admission skin…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-19 · 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 clinical record review and staff interview, it was determined that the facility failed to notify hospice services and the resident's responsible party of a change in condition for one of three residents reviewed (Resident CL1). Findings Include: Review of facility policy titled Change in Resident Condition/Notification with a review date of March 2022 indicated it is the policy of this facility to notify the resident's responsible party/family when there is a significant change in the resident's condition. Additional review of facility policy indicated the licensed nurse or administrator will notify the designated person for notification as soon as possible following a significant change in a resident's condition. Documentation of the time and person notified, or message left, will be noted in the resident's record. Review of Resident CL1's clinical record revealed resident was admitted to the facility on [DATE], with diagnoses including but not limited to following Endocarditis (Inflammation 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.

    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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
NAAMANS CREEK CARE, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/01/2022
DUGGAN, TIMOTHYIndividualCORPORATE DIRECTORsince 05/16/2022
LAKE, BLAIRIndividualCORPORATE DIRECTORsince 01/29/2025
WALDROP, MARKIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/16/2022
CHR CONSULTING SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
EVANS, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/16/2022
LEFF, ALISONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 12 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$9.6M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
$183K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 15%Other / private 22%

This home reported $183K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$369per resident / day
operating cost
$11,219per month
≈ monthly operating cost
$356per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

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 395952. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-26, 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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