Penn Highlands Jefferson Manor

Location & what’s nearby

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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

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.

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

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

42.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 57.6% 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 59 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

Staffing

How full it usually is: this home is certified for 160 beds and averages 89.2 residents a day — about 56% occupied, or roughly 71 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 3.63 hrs/resident/day on weekends vs 3.98 on weekdays — 9% thinner on weekends. RN hours go from 0.79 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

Deficiencies are 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.

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.

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-04-10 · 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 review of clinical records, and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide ideations from attempting to inflict self-harm for one of two residents reviewed with a history of suicide ideation and resulted in an Immediate Jeopardy situation (Resident R3). Findings include: Resident R3's clinical record revealed an admission date of 12/28/23, with diagnoses that included Bipolar Disorder with severe psychotic features (condition characterized by the presence of either delusions or hallucinations or both), major depressive disorder, generalized anxiety disorder, Agoraphobia with panic disorder (phobic-anxious syndrome where patients avoid situations or places in which they fear being embarrassed, or being unable to escape or get help if a panic attack occurs), and post-traumatic stress disorder (mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe…

  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
• Actual harm · G2026-02-03 · 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

  Based on review of facility policy and clinical and facility records and staff interview, it was determined that the facility failed to ensure Resident R1 was free of neglect during care, which resulted in actual harm of a left hip fracture requiring surgical repair for one resident (Resident R1). Findings include: Review of a current facility policy entitled, Abuse-Neglect and Exploitation revealed the following Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas (e.g. absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces, failure to apply safety alarms/devices, failure to follow the resident's plan of care, leaving a resident on the toilet for excessive amounts of time without returning to assist the resident, etc.). Neglect also occurs when a number of residents receive a lack of care in one or more regulatory groupings, a finding which reflects 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-02-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall which resulted in the actual harm of a left hip fracture requiring surgical repair for one resident (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 1/8/24, with diagnoses that included dementia, anxiety, colon cancer and osteoporosis. Resident's R1's Minimum Data Set (MDS - periodic assessment of resident care needs), Section GG0170 Functional abilities Mobility dated 6/27/25, revealed Resident R1 was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) for transfers, changing position in bed and for toilet use. Review of a physician's order dated 10/15/25, directed that Resident R1 be assisted by two staff members while standing at a handrail. Review of physical therapy recommendation dated…

  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 before2025-12-18 · 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 review of facility policies and clinical records, observations and staff interviews, it was determined that the facility failed to follow physician orders for two of 20 residents reviewed (Residents R7 and R16).Findings include: Review of a facility policy Medication Administration dated 4/29/25, revealed all medications are to be administered only as prescribed, and only by licensed practical nursing staff. If a dose of regularly scheduled medication is withheld or refused, the nurse is to pick the correct reason for medication not being given in the eMAR (electronic medication administration record) in the EMR (electronic medication record) for the resident. The nurse is then responsible for notifying the RN Supervisor so that the family and physician can be made aware for further orders. Medications ordered must be available for use and all medications on hand must have a corresponding order. Review of a facility policy entitled Physician Orders dated 4/29/25, revealed Part of the noting process is ensuring that tasks are addressed: additions, changes, corrections, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-18 · 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 review of facility policies and clinical records, and staff interview, it was determined that the facility failed to ensure medications were available from a pharmacy for timely medication administration to meet the needs of the resident for one of 20 residents reviewed (Resident R7). Findings include: Review of a facility policy Medication Administration dated 4/29/25, revealed all medications are to be administered only as prescribed, and only by licensed practical nursing staff. If a dose of regularly scheduled medication is withheld or refused, the nurse is to pick the correct reason for medication not being given in the eMAR (electronic medication administration record) in the EMR (electronic medication record) for the resident. The nurse is then responsible for notifying the RN Supervisor so that the family and physician can be made aware for further orders. Medications ordered must be available for use and all medications on hand must have a corresponding order. Review of a facility policy Preparation & General Guidelines dated 4/29/25, revealed medications are…

  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 · D2025-01-09 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician orders and resident Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 22 residents reviewed (Resident R13). Findings include: The facility policy entitled Advance Directives dated [DATE], indicated that The Director of Nursing Services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care .The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Resident R13's clinical record revealed an admission date of [DATE], with diagnoses that included Type I diabetes (condition where the pancreas makes little or no insulin causing high…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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 and staff interview, it was determined that the facility failed to maintain a clean homelike environment for one of five units (Memory Lane). Findings include: Observation on Memory Lane on 1/06/25, at 3:00 p.m. revealed Resident R70 lying in bed with his/her eyes closed. Resident R70's wheelchair was at bedside and noted to have a dry, white, food-like substance on the seat cushion and on his/her bilateral arm rest. Observation on Memory Lane on 1/07/25, at 9:39 a.m. revealed Resident R1 lying in bed watching television. Resident R1's wheelchair was noted to be in the hallway and was observed to have a dried tan substance running down the left side of his/her seat cushion and the left side of his /her wheelchair base. Observation on Memory Lane on 1/07/25, at 1:00 p.m. revealed Resident R70 sitting in his /her wheelchair in the resident lounge. Resident R70's wheelchair cushion was not visible at time of observation, but bilateral arm rest continued to have a dry white food-like substance present. Observation at this time, also revealed Resident R1 sitting in…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-09 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS - periodic assessment of resident care needs) for two of 22 residents reviewed (Residents R1 and R46). Findings include: Resident R1's clinical record revealed an admission date of 11/04/96, with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 5/20/24, indicating he/she receives Jevity 1.5 (a high…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-09 · 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 review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 22 residents reviewed (Residents R46 and R56). Findings include: Review of Resident R46's clinical record revealed an admission date of 7/7/20, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), and diabetes (a health condition that caused by the body's inability to produce enough insulin). Review of Resident R46's physician's orders revealed an order dated 11/17/24, for staff to turn and reposition every two hours. Review of Resident R46's care plans revealed a care plan for impaired mobility with an intervention to turn and reposition every two hours. Observations on 1/07/25, at 9:25 a.m., 11:20 a.m., 12:30 p.m., 12:50 p.m., 2:00 p.m., at 3:08 p.m., and at 3:15 p.m. all revealed Resident R46 was in his/her bed positioned on his/her buttocks. During an interview on 1/07/25, at 3:16 p.m.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two of two residents reviewed for respiratory services (Residents R51 and R1). Findings include: A facility policy dated 6/11/24, entitled Oxygen Administration indicated Verify that there is a physician's order for this procedure. Review the physician's order . for oxygen administration. Resident R51's clinical record revealed an admission date of 5/02/23, with diagnoses that included chronic obstructive pulmonary disease (COPD - condition when your lungs do not have adequate air flow), and peripheral vascular disease (PVD - a condition when there is restricted blood flow to the limb, usually legs). Resident R51's Care Plan revealed a care plan for altered cardiac output and respiratory function with an intervention of oxygen at 3 lpm (liters per minute) via nasal cannula (a thin tube…

  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 · D2025-01-09 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to label a multi-dose insulin (medication to treat elevated blood sugar levels) vial with the date it was opened, in one of five medication carts (Memory Lane) and failed to ensure medications for self-administration were properly secured for one of 22 residents reviewed (Resident R22). Findings include: Review of the facility policy entitled Vials and Ampules of Injectable Medications dated 6/11/24, indicated vials and ampules medications are used in accordance with the manufacturer's recommendations or the providers pharmacy's directions for storage, use, and disposal. It also indicated that at a minimum, the date opened must be recorded. Review of the facility policy entitled Self-Administration of Medications dated 6/11/24, indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of the residents permitted to self-administer are…

  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 before2025-01-09 · 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

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for two of 22 residents reviewed (Residents R1 and R37). Findings include: Facility policy entitled Documentation dated 6/11/24, indicated to document information as soon as possible to ensure accuracy of the information and to reflect ongoing care and to document only care, treatment, and medication that have actually been provided or administered. Facility policy entitled Enteral Tube Feeding Via Continuous Pump dated 6/11/24, indicated the person performing the procedure should record the amount and type of enteral feeding and the average fluid intake per day. Resident R1's clinical record revealed an admission date of 11/04/96, with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-09 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during observation of tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing) care for one of three residents observed for care requiring EBP (Resident R1). Findings include: A facility policy entitled Enhanced Barrier Precautions dated 6/11/24, indicated that Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms to residents. The policy further stated that high contact resident care activities that require the use of gown and gloves for EBP's included devise care or use such as tracheostomies and that face protection may be used if there is also a risk of splash or spray. Resident R1's clinical record revealed an admission date of 11/04/96, with diagnoses that included tracheostomy (a hole made through the front 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.

  Infection Control 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.

Fines & penalties

$15,160 in federal fines across 2 penalties.

• $12,015 — penalty dated 2024-03-08
• $3,145 — penalty dated 2023-09-11

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.

Who owns this facility

CMS files one row per role, so the 80 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

This home reported $1.5M 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in PA