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Meadows Nursing And Rehabilitation Center

4 East Center Street, Dallas, PA 18612 · Non profit - Corporation · 130 certified beds · (570) 675-8600 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse2 actual-harm citations$52,135 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $52,135 in federal fines (most recent 2024-05-21)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
113 North Memorial Highway · (570) 674-6525 · Call to confirm hours
Pharmacy
1909 Memorial Hwy · (570) 675-1191 · Call to confirm hours
Grocery
148 Memorial Hwy · (570) 674-6034 · Call to confirm hours
Park
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 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 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.4%16.8%15.4%worse
Long-stay residents who lose too much weight13.1%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.7%0.7%0.9%worse
Long-stay residents with a urinary tract infection3.3%1.5%2.0%worse
Long-stay residents with depressive symptoms0.3%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury1.2%3.1%3.3%better
Long-stay residents whose ability to walk worsened23.9%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.5%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine97.5%93.5%95.3%typical
Long-stay residents with pressure ulcers9.3%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control32.5%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.4%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.2%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine91.0%68.7%79.4%better
Short-stay residents rehospitalized after admission10.9%22.5%22.6%better
Short-stay residents with an outpatient ER visit9.1%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days0.821.621.67better
Long-stay outpatient ER visits per 1,000 resident days1.031.181.80better

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

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

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

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

51.2% 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 293 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.2%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
47.0%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 47.0% 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 183 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.2%CMS range 45.5–55.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.6–13.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge47.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.6%CMS range 7.0–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.69
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.80
Total nurse hours/ resident / day
0.36
RN hoursweekends
30.2%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 118.1 residents a day — about 91% occupied, or roughly 12 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 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.35 hrs/resident/day on weekends vs 3.99 on weekdays — 16% thinner on weekends. RN hours go from 0.82 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% 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

7
deficiencies at the latest standard inspection (2025-07-31)
6
at the previous standard inspection (2024-09-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2025-05-30 · 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 a review of clinical records, the facility's abuse prohibition policy, select investigative documentation, and interviews with the resident and facility staff, it was determined the facility failed to protect one of five sampled residents (Resident 18) from neglect by not implementing the physician-ordered use of a mechanical lift for all transfers, resulting in actual harm in the form of a comminuted right tibia and fibula fracture requiring surgical intervention. Findings include: A review of the facility policy titled Investigation of Allegations of Abuse, Neglect or Misappropriation of Resident Property provided on May 30, 2025, revealed the facility will provide each resident with the highest practicable physical, mental and psychological services to meet their individual needs and promote or maintain the resident at their highest level of wellbeing. This includes the protection of Resident's Rights. Allegations of abuse will be thoroughly investigated by the facility. The policy defines neglect as the failure of the facility, its employees, or service providers 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-05-21 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 review of clinical record and select facility incident reports, and staff interview it was determined that the facility failed to assure that one resident of five sampled (Resident CR1) was free from a significant medication error that compromised the resident's clinical condition and health due to Tacrolimus toxicity. Findings include: Clinical record review revealed that Resident CR1 was admitted from the hospital to the facility on [DATE], with diagnoses, which included pneumonia and history of a kidney transplant. Review of medications listed on Resident CR1's Hospital Discharge Instructions revealed that active medications to continue at the long term care nursing facility included Tacrolimus (immunosuppressive agent used in the prevention and treatment of solid-organ transplant rejection) 0.5 mg capsule, take 2 capsules in the morning, and 1 capsule in the evening. Review of Resident CR1's admission physician orders dated [DATE], revealed an order for Tacrolimus 5 mg 2 capsules by mouth once daily…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, documentation provided by the facility, and staff and resident interviews, it was determined the facility failed to protect one of 24 sampled residents (Resident 74) from sexual abuse perpetrated by another resident (Resident 12).Findings include: A review of the facility policy titled Investigation of Allegations of Abuse, Neglect, or the Misappropriation of Resident Property, last reviewed by the facility on March 1, 2026, revealed it is the facility policy to provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and promote or maintain the resident's highest level of well-being. This includes the protection of residents' rights. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods…

    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 plan of correction
  • Potential for harm · D2026-05-29 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, documentation provided by the facility, and staff interviews, it was determined the facility failed to implement abuse prevention and investigation procedures for one of 24 residents reviewed (Resident 74) following an allegation of resident-to-resident sexual abuse involving Resident 12.Findings include: A review of the facility policy titled Investigation of Allegations of Abuse, Neglect, or the Misappropriation of Resident Property, last reviewed by the facility on March 1, 2026, revealed it is the facility policy to implement residents' rights to the fullest intent of the law. To protect the resident and determine the direction of the investigation, the policy requires facility staff to: Immediately separate residents and assess for possible injury.Immediately initiate an investigation and remove the alleged perpetrator.Arrange for medical attention, including a forensic rape exam for suspected sexual abuse.Obtain written statements from appropriate…

    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 plan of correction
  • Potential for harm · Dcited before2026-02-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, facility-provided documentation, and staff interviews, it was determined the facility failed to ensure timely, comprehensive assessment and monitoring of wounds and failed to ensure implementation of necessary practices to prevent worsening skin breakdown for 1 of 7 residents reviewed (Resident 1).Findings include:According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the best pressure ulcer practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, facility policies, facility investigative documentation, manufacturer instructions, and staff and resident interviews, it was determined the facility failed to implement interventions to prevent the development of a pressure injury for two residents (Residents 58 and 6) and failed to implement physician-ordered pressure-relief measures for two residents (Residents 11 and 70) out of 28 residents reviewed. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the best pressure ulcer practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-31 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, documentation provided by the facility, and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's dignity for one out of 28 residents sampled (Resident 83).Findings include:A clinical record review revealed Resident 83 was admitted to the facility on [DATE], with diagnoses to include peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). During an observation conducted on July 29, 2025, at 9:48 AM, Employee 10, Nurse Aide (NA), was seen transporting Resident 83 in a white shower chair through the third-floor 300s unit hallway in route to the shower room. Resident 83 was wearing only a black t-shirt that extended to his waist and was not wearing pants. A white cloth was loosely draped across the resident's lap. Resident 83's buttocks and approximately four inches of his gluteal cleft (the groove between the buttocks) were visibly exposed as he 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-31 · 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 observation and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, safe, orderly and sanitary resident environment in the room of one of 28 residents reviewed. (Resident 2) Findings include: Observations of Resident 2's room on the [NAME] unit, on July 29, 2025, at 1036 AM, revealed a fitted bed sheet with an approximately 6-inch x6-inch tan stain noted to be on the left side middle portion of the fitted sheet.An observation to Resident 2's room on July 30, 2025, at 10:47 AM revealed the fitted bed sheet noted an approximately 6 -inch by 6 -inch tan stain noted to be on the left side middle portion of the bed. Further observation revealed a 7- inch by 6-inch tan stain noted on the lower right side of the fitted sheet. Additionally, noted to be at the foot of fitted sheet were 4 8-inch streaks of a dark red substance running along the foot of the fitted sheet.An observation made in Resident 2's room on July 30,2025 at 1:00 P.M. revealed the fitted bed sheet noted an approximately 6- inch by…

    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 · D2025-07-31 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined the facility failed to fully develop and revise a person-centered comprehensive care plan to meet the individualized needs of two residents out of 28 sampled (Resident 7 and 41).Findings included: A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (a condition in which the heart doesn't pump blood as well as it should) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin (a hormone that helps regulate blood sugar levels) or when the body cannot effectively use the insulin it produces). A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 11, 2025, revealed that Resident 7 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status a tool within the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 28 residents sampled (Resident 18).Findings include: A review of the facility policy titled Restorative Nursing Program, last reviewed by the facility on June 30, 2025, revealed it is the facility's policy to provide a restorative nursing program that focuses on achieving and/or maintaining optimal function in accordance with a comprehensive assessment and plan of care. The policy indicated the restorative nurse monitors on an ongoing basis all aspects of the individualized restorative nursing programs offered and oversees documentation by nurse aides. A clinical record review revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include inflammatory Poly arthropathy (a condition where multiple joints are inflamed). A…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-31 · 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 observations, review of clinical records, facility investigative documentation, and resident and staff interviews, it was determined the facility failed to ensure the residents environment remains free of accident hazards for one out of 28 residents sampled (Resident 92).Findings include: A clinical record review revealed Resident 92 was admitted to the facility on [DATE], with diagnoses that include peripheral vascular disease (condition in which narrowed arteries reduce blood flow to the arms or legs) and neuropathy (a condition in which nerve damage interferes with the functioning of the nervous system). A review of an Annual Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 25, 2025, revealed that Resident 92 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-20 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident council meeting minutes, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one resident out of 23 sampled (Resident 40) and experiences expressed by two residents during a group interview (Residents 78 and 79). Findings include: A review of policy titled Restorative Nursing Policy, last reviewed by the facility on April 3, 2024, revealed it is the policy of the facility to provide a restorative nursing program that focuses on achieving and maintaining optimal function in accordance with the comprehensive assessment and plan of care. The policy indicates that residents who are referred by physical therapy, physician, or nursing will be evaluated by the restorative nurse for a restorative program. Also, it is the commitment of the facility to assist residents to restore or maintain…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-09-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical needs for one of 23 residents reviewed (Residents 34). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A clinical record review revealed Resident 34 was admitted to the facility on [DATE], with diagnoses that include degenerative disease of the nervous system (a condition that affects many of the body's activities, such as balance, movement, talking, breathing, 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 · D2024-09-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy review, and staff interview it was determined the facility failed to ensure a physician ordered fluid restriction was maintained for one of 23 sampled residents (Resident 1). Findings include: Review of the facility Intake and Output Monitoring Policy, last reviewed April 3, 2024, indicated that intake and output (intake refers to the amount of fluids the resident ingests, and output refers to the amount of fluids that leave the body) will be monitored on residents as necessary with documentation in the Electronic Medical Record. All residents on fluid restrictions will remain on intake and output if specifically ordered, and as clinical needs indicate. Intakes will be reviewed daily by the 3:00 PM to 11:00 PM RN Charge Nurse/designee to see if resident is meeting estimated fluid requirement or is over fluid restriction. The physician is to be made aware if the resident is over fluid restriction times two days or is under estimated fluid requirement…

    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 · D2024-09-20 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of select facility policy, and staff interview it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs by failing to monitor intravenous therapy (way of giving medication or fluids through a needle or tube inserted into a vein) in accordance with professional standards of practice for two of two reviewed residents receiving intravenous therapy (Residents 94 and 1) Findings include: A review of the facility Insertion of Peripheral IV (Over the needle, Peripheral Short) catheter policy last reviewed April 3,2024, indicated that all IV insertions should be labeled with date and time of insertion. Further review of the Insertion of Peripheral IV (Over the needle, Peripheral Short) catheter policy revealed the IV is to be removed after medication therapy is completed or discontinued. A review of clinical records revealed that Resident 94 was admitted to the facility on [DATE], with diagnoses which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-21 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy, and select facility incident investigations, and staff interview, it was determined that the facility neglected to provide the care and services necessary to prevent physical injury or harm for two out of five residents sampled (Residents CR2 and 26). Findings include: A review of the facility's Investigation of Allegations of Abuse, Neglect, or Misappropriation of Resident Policy last reviewed May 2023, indicated as last reviewed by the facility on November 1, 2023, revealed that the facility will provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and to promote or maintain the resident at their highest level of well-being. Allegations of abuse, defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish, as well as neglect, financial exploitation or misappropriation 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-11 · tag F0641 — pattern
    Ensure 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 a review of clinical records, the Resident Assessment Instrument, and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of four residents out of the 18 sampled (Residents 22, 31, 62, 142). Findings include: A review of the clinical record revealed that Resident 22 was admitted to the facility on [DATE]. A review of Resident 22's annual MDS assessment dated [DATE], revealed in Section I. Active Diagnoses. I6000. Schizophrenia was coded Yes and indicate that the diagnosis was a primary reason for admission. Review of Resident 22's quarterly MDS dated [DATE], revealed that Identified that Resident 22's May 5, 2023, Quarterly MDS Section I. Active Diagnoses. I6000. Schizophrenia was coded No. Interview with the Nursing Home Administrator on August 10, 2023, at 12:20 PM, revealed that Resident 22 had a history of mental…

    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 before2023-08-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and a staff interview, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean, orderly, and homelike environment in resident areas on one of two resident units (Unit 3). Findings include: An observation on August 8, 2023, at 10:45 a.m., of resident room [ROOM NUMBER] revealed black and gray scuff marks, areas of chipped paint, and dozens of scratches in the dry wall on the wall adjacent to the door-side bed and on the wall to the left of the restroom door. The heating and cooling unit in the room was observed to have black and gray scuff marks running along the bottom portion of the entire unit, approximately covering 4.0 feet x 0.5 feet of the unit. The window-side wall was observed to have two 1.5-inch holes penetrating through the drywall. An observation on August 10, 2023, at 11:30 a.m. of resident room [ROOM NUMBER] revealed black and gray scuff marks, areas of chipped paint, and scratches in the dry wall on the lower portion 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy, and staff interview it was determined that the facility failed to monitor bowel activity and implement physician's ordered bowel protocol to promote bowel activity for one resident (Resident 76) out of 18 sampled residents. Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week. A review of Resident 76's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of compression fractures [are small breaks or cracks in the vertebrae (the bones that make up your spinal column] of the first lumbar [(L1) is the first of the series and are the lumbar vertebrae…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 18 residents sampled (Resident 26). Findings included: A review of Resident 26's clinical record revealed a Suspected UTI SBAR (Situation-Background-Assessment-Recommendation) dated July 18, 2023, indicating that Resident 26 had experienced increased urinary frequency. According to the document, the resident did not have an indwelling catheter, incontinence, or new/worsening symptoms, and that the resident did not need an immediate prescription for an antibiotic, but may need additional observation. The physician ordered a urinalysis and culture and sensitivity (report to indicate what antibiotic will treat the infection) to rule out a urinary tract infection. Nursing documentation dated July 19, 2023, at 3:45 p.m. indicated that the physician was aware of the urinalysis results and ordered Augmentin 500 mg orally twice a day for 5 days. The urine culture and sensitivity report,…

    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
  • No harm found · B2025-07-31 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility-initiated transfer notices, and staff interviews, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for 2 out of 28 residents reviewed (Residents 41 and 70).Findings include: A review of the clinical record revealed that Resident 41 was transferred to the hospital on May 13, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 70 was transferred to the hospital on April 28, 2025, and was readmitted to the facility on [DATE]. Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the Nursing Home Administrator on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-09-20 · tag F0622 — pattern
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a clinical record review and staff interview, it was determined the facility failed to ensure that necessary resident information was communicated to the receiving health care provider for one resident out of 23 residents sampled with facility-initiated transfers (Residents 27). Findings include: A review of Resident 27's clinical record revealed that the resident was transferred (the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility) to the hospital on August 28, 2024, and returned to the facility on September 5, 2024. There was no documented evidence the facility had communicated specific information to the receiving health care provider for the resident transferred and expected to return, which included the resident's care plan goals and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on September 20, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed there was no evidence…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-09-20 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of clinical records and staff interview it was determined that the facility failed to provide residents or their representatives with written information of the facility's bed hold policy upon transfer to the hospital of two residents out of 23 residents sampled (Residents 96 and 27). Findings include: A review of Resident 96's clinical record revealed the resident was transferred to the hospital on July 4, 2024, and returned to the facility on July 9, 2024. A review of Resident 27's clinical record revealed the resident was transferred to the hospital on August 28, 2024, and returned to the facility on September 5, 2024. There was no documented evidence the facility provided these residents and/or their representatives written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) at the time of the transfer. Interview with the administrator on September 19, 2024, at approximately 1:00 PM confirmed the facility was unable to provide documented evidence of the provision 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-08-11 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide written notice of facility-initiated resident transfer to the hospital identifying the reason for the transfer in a language and manner easily understand to the resident and the resident's representative for one resident out of 18 residents sampled. (Resident 37). Findings include: A review of Resident 37's clinical record revealed that the resident was transferred to the hospital on July 1, 2023, and returned to the facility on July 5, 2023. Review of the facility's notice of transfer or discharge revealed that Resident 37 was transferred to the hospital because her needs cannot be met at the current facility. Interview with the Nursing Home Administrator on August 11, 2023, at approximately 10:30 a.m. confirmed that Resident 37's reason for the transfer was not written in a language and manner easily understood. 28 Pa. Code 201.14(a) Responsibility of Licensee

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$52,135 in federal fines across 1 penalty.

  • $52,135 — penalty dated 2024-05-21

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

Owner / managerTypeRoleShareSince
ECUMENICAL ENTERPRISES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF100%since 08/26/1983
BRENSHA, LYNNEIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
BROBST, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
BROWN, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
BUCHMAN, DANAIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
DOYLE, JOSEPHIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
FETTERMAN, KURTIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
HOFFMAN-MIRILOVICH, ALISHAIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
KORNFELD, TALYIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
MESSINGER, JANEIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2020
PAYNE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
RUDIS, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2018
SANDS, ALLENIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2022
SCHWAGER, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
SOLANO, JAMESIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
THALENFELD, REBECCAIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2024
ZANICKY, ROBERTIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2018
TARBOX, CRISTINAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 03/20/2025
ZAMBER, LISAIndividualCORPORATE DIRECTORsince 08/01/2018
CADORA-COX, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/30/2024
ALMEKY, ESSAMIndividualADP OF THE SNFsince 01/01/2023
IM, MICHELLEIndividualADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 26 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$13.5M
Net patient revenuemost recent cost report
-3.5%
Operating marginrevenue minus expenses
$556K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 16%Other / private 29%

This home reported $556K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$389per resident / day
operating cost
$11,829per month
≈ monthly operating cost
$376per day
avg. revenue, all payers

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

What families pay in PA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395587. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-31, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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