Transitions Healthcare Shook Home
55 South Second Street, Chambersburg, PA 17201 · For profit - Limited Liability company · 65 certified beds · (717) 264-6815 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $205,694 in federal fines (most recent 2024-05-30)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 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 held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.6% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 11.3% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.9% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.6% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.4% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 24.6% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 24.5% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.2% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 29.9% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.3% | 68.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 19.2% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.9% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.54 | 1.62 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.95 | 1.18 | 1.80 | typical |
§ 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.
44.4% 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 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.1% 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 94 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.4%CMS range 37.6–52.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.8–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 47.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 3.6–9.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 65 beds and averages 60.2 residents a day — about 93% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.50 hrs/resident/day on weekends vs 4.17 on weekdays — 16% thinner on weekends. RN hours go from 0.88 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% 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
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.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-06-20 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, hospital record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided after a change in condition for one of 16 residents reviewed (Resident 1). This failure resulted in continued decline, which required hospitalization for hypovolemic shock (emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body), low blood pressure, and cardiac arrest for Resident 1. This failure placed an additional six out of six residents reviewed who were identified as having a change in condition in an immediate jeopardy situation (Residents 9, 12, 13, 14, 15, and 16). The facility also failed to monitor blood glucose levels for residents with Diabetes Mellitus for two of 16 residents reviewed (Resident 1 and 9). Findings include: Review of facility policy, titled Change of Condition, with a last revision date of February 22, 2024, revealed the following: It is…
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.
- Immediate jeopardy · J2024-06-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, hospital record review, and resident representative and staff interviews, it was determined that the facility failed to notify the physician after a change in a resident's condition and failed to notify a resident's representative of a change in treatment for one of four residents reviewed (Resident 1). Immediate Jeopardy was identified because the failure to notify the physician resulted in a lack of physician oversight. This caused a delay in treatment, which resulted in transfer to the hospital for hypovolemic shock (emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body), hypotension (low blood pressure), hyperglycemia (elevated blood sugar), and cardiac arrest for Resident 1. Findings include: Review of facility policy, titled Change of Condition, with a last revision date of February 22, 2024, revealed the following: It is the policy of the Facility to inform residents, physicians/CRNP's (Certified Registered Nurse Practitioners), and resident representatives…
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.
- Actual harm · G2025-07-22 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, hospital record review, facility investigation report, facility provided documents, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to prevent a significant medication error, which resulted in actual harm as evidenced by a hospital transfer for low blood pressure, low heart rate and altered consciousness for one of three residents reviewed (Resident 1).Findings include: Review of facility policy, titled CLIN-080 Medication Pass, revealed the following, in part, 2. The MAR [Medication Administration Record] is reviewed for the right resident, right drug, right time, right route, and right dose. 3. As the medications are being poured, the licensed nurse compares the label with the MAR three times: a. When removing medication from the drawer, b. When removing the medication from the container, c. when returning the container to the drawer. 5. The resident is properly identified by 2 forms of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-05 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 16 residents reviewed (Resident 11).Findings include: Review of Resident 11's clinical record revealed diagnoses that included dementia (a chronic disorder of mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and hypertension (high blood pressure). Review of Resident 11's current physician orders revealed an order for losartan potassium 50 milligram tablet give one tablet by mouth one time a day hold for systolic blood pressure less than 100 or blood pressure less than 100/60, dated October 15, 2025. Review of Resident 11's Medication Administration Records from October 15, 2025, through March 4, 2026, revealed the following:1) There was no documentation of Resident 11's blood pressure documented with each medication administration.2) The losartan was coded as 5=Hold See Progress Notes on November 2 and 7, 2025, and December…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in two of two kitchenettes, and a resident unit refrigerator (second floor upper-level unit).Findings include: Review of facility policy, titled Food Storage, dated 2021, revealed, in part, All stock must be rotated with each new order received. Rotating stock is essential to assure freshness and highest quality of all foods. Old stock is always used first. Food should be dated as it is placed on shelves if required by state regulation. All containers or storage bags must be legible and accurately labeled and dated. All refrigerator units should be kept clean and in good working condition at all times. Every refrigerator must be equipped with a thermometer. Refrigerators/freezers on nursing units should be supplied with thermometers. All [refrigerated] foods should be covered, labeled, and dated and routinely monitored.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, facility document review, observations, and resident and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for one of 16 residents reviewed (Resident 56).Findings include: Review of facility policy, titled OPS-331 Resident Rights, dated February 6, 2025, revealed, in part, The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Review of facility provided information from their employee handbook, dated November 1, 2203, revealed, in part, F. Dress Code Policy: Since the appearance of the staff is a reflection of the employee, the resident, and the Company, the dress code provides for a consistent professional appearance in the dress of the staff. Should an employee report to work improperly dressed or groomed, his/her supervisor may instruct the employee to return home to change. Employees will not be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan to meet a resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of 16 residents reviewed (Resident 3).Findings include: Review of facility policy, titled Care Plan-Comprehensive, dated September 28, 2022, revealed, in part, Each resident will have a comprehensive care plan that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflects the resident's cultural references, values, and practices. Each resident's care plan is designed to: d. reflect the resident's expressed wishes regarding care and treatment goals. Review of Resident 3's clinical record revealed diagnoses that included muscle weakness and depression. During a resident interview with Resident 3 on March 2, 2026, at 1:40 PM, he indicated that he does…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 19 residents reviewed (Residents 4, 56, and 60).Findings include: Review of the facility policy, titled Care Plan-Comprehensive, last reviewed April 7, 2025, stated Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of Resident 4's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body). Review of Resident 4's clinical record revealed that he was treated for the flu from January 30, 2026 -February 6, 2026. Review of Resident 4's care plan revealed an active care plan focus for influenza, dated January 30, 2026. During a staff interview with the Director of Nursing on March 5, 2026,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observations, facility policy, and staff interviews, it was determined that the facility failed to discard expired medications for one of one medication storage rooms observed (2nd floor), and failed to place opened dates on medications in one of two medication carts (2nd floor) and one of one medication storage rooms (2nd floor) observed. Findings Include: Review of facility policy, titled Storage of Medications, last revised April 7, 2025, read, in part, III. Expiration Dating (Beyond-Use Dating) 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. Observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one open multidose vial of tuberculin solution with no open date label. Further observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one box of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ddisputed · IDR2026-03-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of 19 residents observed on contact precautions (Resident 5).Findings Include: Review of facility policy, titled IC-Enhanced Barrier Precautions, revised April 1, 2024, revealed, Enhanced barrier precautions apply when: A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and contact precautions do not otherwise apply. Review of Resident 5's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 3 (a severe, full-thickness wound where the true depth [Stage III or IV]) and diabetes (a chronic condition when the body cannot properly control blood glucose levels). [[NAME]] I feel the ulcer piece isn't finished…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ddisputed · IDR2026-03-05 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, other resources, and staff interviews, it was determined that the facility antibiotic stewardship program allows for lapsed doses of antibiotic usage as determined by one of 19 residents reviewed (Resident 60).Findings Include: Review of the facility policy, titled Antibiotic Stewardship- Order for Antibiotics, reviewed April 7, 2025, When a culture and sensitivity (C&S) is ordered, it will be completed, and; lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Based on National Institute of Health Resource, dated December 11, 2025, lapsed or missed doses particularly early in treatment are critical issues that reduce treatment efficacy, allow for the development of drug resistance, and may necessitate dose increases or adjustments. Based on current Food and Drug Administration recommendations the treatment for Proteus mirabilis (Gram negative rod bacteria capable of causing symptomatic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-03 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined that the facility failed to post the most recent Federal or State survey results for one of one survey books observed (located in main entrance lobby). Findings Include: Observation of the survey binder located in the main entrance lobby on April 1, 2025, at 11:27 AM, revealed the most recent survey results present were dated August 2023. Review of the facility's survey history revealed the most recent survey result that could have been posted was conducted on March 19, 2025. During an interview with the Nursing Home Administrator on April 2, 2025, at 1:02 PM, he revealed the expectation that the survey books should be up to date and confirmed that they had been updated. 28 Pa. Code 201.14 Responsibility of licensee
- Potential for harm · E2025-04-03 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide a notice of transfer that included the required information for three of four resident records reviewed for hospitalizations (Residents 47, 50, and 58). Findings include: Review of Resident 47's clinical record revealed diagnoses that included atrial fibrillation (irregular and rapid heartbeats on the upper chamber of the heart) and acute kidney failure (a sudden and significant decrease in kidney function). Further review of Resident 47's clinical record revealed that she had been transferred and admitted to the hospital on [DATE]. Review of facility provided document, titled Notice of Proposed Involuntary Discharge or Transfer, revealed the notice did not contain the location of transfer, statement of the Resident's appeal rights, the mailing address of the entity which receives request for appeals; mailing address of the Office of the State Long-Term Care Ombudsman; the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · E2025-04-03 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to monitor hydration to ensure proper hydration for one of two residents reviewed for hydration (Resident 50). Findings include: Review of facility policy, titled CLIN-054 Fluid Intake with a last review date of December 2024, failed to reveal how the facility would manage fluid intake for residents with physician ordered restrictions. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and chronic respiratory failure with hypoxia (long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 50's clinical record revealed a physician order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, facility policy review, and staff interviews, it was determined that the facility failed to ensure food was prepared and served under sanitary conditions in two of two dining rooms observed (1st and 2nd floor). Findings include: Review of facility policy, Bare Hand Contact with Food and Use of Plastic Gloves, dated 2021, revealed, Bare hand contact with food is prohibited .Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single-use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single-use gloves. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. Observation of tray line service on second floor on March 31,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, review of select facility documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of two residents reviewed for abuse (Resident 52). Findings include: Review of facility policy, titled Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, revised June 14, 2023, revealed, This facility's policy is to immediately report and investigate all allegations of mistreatment, neglect, abuse, misappropriation of a resident's property or any injury of unknown origin .Facility staff will be trained to report any oral or written reports of alleged neglect, abuse, mistreatment, and misappropriation of resident's property .Any report or suspicion of an incident is to be reported immediately to the charge nurse/supervisor .The Administrator and the Director of Nursing are to be notified immediately by the charge nurse/supervisor who receives the report. The Administrator or his designated person will notify the Licensing and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 17 residents reviewed (Residents 13 and 24). Findings include: Review of facility policy, titled Care Plan - Comprehensive, last reviewed December 2024, revealed, Each resident will have a comprehensive care plan developed that is individualized, included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. Review of Resident 13's clinical record revealed diagnoses that included atrial fibrillation (upper chambers of the heartbeat irregularly and rapidly) and heart failure (the heart cannot pump effectively enough to meet the body's needs). Review of Resident 13's physician orders revealed an order for Apixaban (anticoagulant medication) 2.5 milligrams…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
Based on facility policy review, review of facility admission agreement, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of 21 residents reviewed (Residents 48 and 55). Findings include: Review of facility policy, titled Care Plan - Comprehensive, revised September 28, 2022, revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of Resident 48's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression. Review of Resident 48's clinical record progress notes revealed a nurse's note dated March 17, 2025, at 1:52 PM, that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure each resident's highest level of well-being for one of three residents reviewed for advanced directives (Resident 51). Findings Include: Review of Resident 51's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). Further review of Resident 51's clinical record revealed a POLST form (Pennsylvania Orders for Life Sustaining Treatment), dated December 23, 2024, stating that if Resident 51 was found with no pulse and not breathing, Resident 51 did not wish to be resuscitated. Review of Resident 51's physician orders revealed an order dated July 3, 2024, for Full Code, meaning resuscitation should be attempted if she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, record review, observation, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for one of one resident reviewed (Resident 49). Findings Include: Review of facility policy, titled CLIN-046 Dressing Changes, Revised March 28, 2016, revealed in step 11. Write the date, time, and initials on the dressing. Review of facility policy, titled IC- Enhanced Barrier Precautions, with a revision date of April 1, 2024, indicated that residents on enhanced barrier precautions require the use of gloves and a protective gown for high contact resident care activities, including wound care and any skin opening requiring a dressing. Review of Resident 49's clinical record revealed diagnoses that included pressure ulcer of right heel (localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time) and diabetes (a disease that effects how the body utilizes and regulates blood sugar).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of three residents reviewed for respiratory care (Resident 50). Findings include: Review of facility policy titled CLIN-009 Aerosol Therapy, with a last review date of December 2024, revealed: Following the treatment remove any medication left in the medication cup of the nebulizer. Wash the nebulizer with tap water after shaking excess medication from assembly, then disassemble nebulizer and place on a paper towel and allow to air dry. Rinse the mask and/or mouthpiece with warm water for 30 seconds. Also air dry on a clean paper or towel. When nebulizer equipment is dry, place it back in labeled plastic bag. Plastic bag will have the date that the equipment was opened on the outside of the bag. Once a week, replace all disposable parts. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-03 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor psychotropic medications to ensure that residents were free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 24). Findings include: Review of facility policy, Use of Psychotropic medications, revised January 21, 2025, revealed, Complete 'Behavior/Interventions' Sheet or other behavior tracking pharmacy form to include : All relevant resident data, target behavior, record the number of episodes, intervention code and outcome by shift, if side effects observed enter code, otherwise leave blank. Review of Resident 24's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 24's physician orders revealed an order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-03 · tag F0806 — failed to honor food preferences — isolatedEnsure 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, clinical record review, review of select facility documents, and staff interviews, it was determined that the facility failed to ensure that residents were served food that accommodated their allergies and intolerances for one of 17 residents reviewed (Resident 32). Findings include: Review of Resident 32's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident 32's physician's orders revealed an order for a gluten free, lactose free diet effective July 7, 2023., Observation of Resident 32 on March 31, 2025, at 12:51 PM, revealed she was served and consumed a cheeseburger on a bun. During an interview with Employee 5 (Dietary Aide) on March 31, 2025, at 12:58 PM, she confirmed that she had not served Resident 32's burger on a gluten free bun. She also confirmed that she has mistakenly served…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and to promote dignity related to use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of three residents reviewed for catheter use (Resident 1). Findings Include: Review of facility policy, titled Catheter Care - Routine, revised March 21, 2016, revealed, Provide privacy cover for drainage bag as needed. Review of facility policy, titled, Catheterization - Foley, revised January 23, 2017, revealed, Keep the catheter bag below the level of the bladder at all times. Do not rest the bag on the floor. Review of Resident 1's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and protein-calorie malnutrition (insufficient protein intake or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-30 · tag F0657 — failed to keep the care plan current — patternDevelop 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 facility policy reviews, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident care plan was reviewed and revised to reflect the resident's current status for four of 15 residents reviewed (Residents 18, 27, 41, and 45). Findings include: Review of facility policy, titled Care Plan-Comprehensive, last revised September 28, 2022, stated, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition, d. At least quarterly. Review of facility policy, titled Bed System Safety, revised July 2, 2019, revealed that the interdisciplinary team will review bed system evaluations and develop the appropriate care plan for the use of positioning devices and side rails. Review of Resident 18's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 15 residents reviewed (Residents 7, 27, and 41). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included muscle weakness and other abnormalities of gait and mobility (difficulty walking caused by various conditions). Review of facility incident reports dated March 11 and 12, 2024, revealed that Resident 7 experienced a fall on each of those dates when she was lowered to the floor by staff. Review of Resident 7's April 24, 2024, comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed it was coded to indicate that Resident 7 had not experienced any falls since her last assessment dated [DATE]. In email correspondence received from the Nursing Home Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for three of 15 residents reviewed (Residents 7, 41, and 154). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 7's May 2024 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Aripiprazole (antipsychotic medication) one time a day for mood related to major depressive disorder and generalized anxiety disorder, effective…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide care and services to prevent and treat pressure injuries in accordance with professional standards for one of three residents reviewed for pressure injuries (Resident 9). Findings include: Review of Resident 9's clinical records revealed diagnoses that included dementia (progressive, irreversible degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and end stage renal disease (severely compromised ability of the kidneys to filter toxins from the blood). Review of Resident 9's physician orders revealed an active order which stated, Monitor dry blisters on toes - if drainage noted, apply Mepilex transfer and [dressing] and schedule to change [Monday, Wednesday, Saturday and as-needed], dated July 6, 2022. During a treatment observation on May 29, 2024, at approximately 11:41 AM, Resident 9 was observed to have an open blister to the outer aspect of her right fifth toe. The area…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 clinical record review and resident and staff interviews, it was determined that the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for two of 18 residents reviewed (Residents 7 and 154). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 7's May 2024 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Aripiprazole (antipsychotic medication) one time a day for mood related to major depressive disorder and generalized anxiety disorder, effective April 18, 2023. Further 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.
- Potential for harm · D2024-05-30 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon for two of 5 residents reviewed for unnecessary medications (Residents 7 and 41). Findings include: Review of facility policy, titled Medication Regimen Review - Pharmacy, revised August 10, 2017, revealed that the medication regimen of each resident is reviewed by a licensed pharmacist according to federal, state, and local regulations. The pharmacist must report any irregularities to the attending physician, the facility's medical director, and the Director of Nursing (DON), and that these reports must be acted upon in a manner that meets the needs of the residents. Upon receipt of the written consultant pharmacist report for non-urgent recommendations, the DON or designee shall provide the report to the attending physician or their designee within 7 days, and 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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$205,694 in federal fines across 1 penalty.
- $205,694 — penalty dated 2024-05-30
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 TRANSITIONS HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 5 of 5 | 3.0 | +2.0 vs chain |
| Quality measures | 2 of 5 | 3.2 | -1.2 vs chain |
The other 5 homes this chain runs (chain average 2.7★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FELDMAN, MARC | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 33% | since 12/01/2023 |
| MAURANO, MATTHEW | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 33% | since 12/01/2023 |
| WILLIAMS, KEVIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 33% | since 12/01/2023 |
| MEMBERS FIRST FEDERAL CREDIT UNIONS | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 12/01/2023 |
| DECORT, RYAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2023 |
| FLASHER, DOUGLAS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2023 |
| TRANSITIONS HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2023 |
CMS files one row per role, so the 19 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.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395918. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.