St Francis Center For Rehabilitation & Healthcare
1412 Lansdowne Avenue, Darby, PA 19023 · For profit - Limited Liability company · 273 certified beds · (610) 461-6510 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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.
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 | 5.6% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.0% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 35.1% | 10.8% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.1% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.9% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.9% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.5% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.4% | 25.5% | 21.2% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 56.4% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.6% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.4% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.40 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.10 | 1.18 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
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.
47.5% 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 121 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.5% 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 135 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 53% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
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 | 47.5%CMS range 40.4–56.0 | 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 | 11.2%CMS range 7.8–14.1 | 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 | 58.5% | 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 | 55.6% | 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 | 49.6% | 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 | 98.4% | 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 | 0.3% | 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 | 2.1% | 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 | 6.3%CMS range 4.0–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.23 | 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 273 beds and averages 252.4 residents a day — about 92% occupied, or roughly 21 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 3.12 hrs/resident/day on weekends vs 3.51 on weekdays — 11% thinner on weekends. RN hours go from 0.41 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above 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 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.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2026-06-05 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, review of clinical record, and interview with staff it was determined that the facility failed to ensure that residents/resident's next of kin/legal guardian/power of attorney are notified of changes in resident's care related to ankle monitoring bracelet for one of 37 residents reviewed (Resident R175). Review of facility policy on notification and change of condition, revised May 2025, revealed that the facility shall utilize a notification process when there is change in the resident's medical condition and or status. Unless otherwise instructed by the resident, a nurse will notify the residents' representative Review of Resident R175's clinical record revealed that Resident R175 has a diagnosis of anxiety disorder (intense, excessive, persistent worry or fear) and unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Observation conducted on June 2, 2026, at 11:24 a.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-05 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide written notice of a room change for one of 37 residents reviewed (Resident R105). Findings Include:Review of Resident R105's clinical record revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Interview with Resident R105 on June 2, 2026, revealed on May 28, 2026, his/her room was moved from room [ROOM NUMBER] to room [ROOM NUMBER]. Resident R105 further reported being unhappy with the room move and was not informed why he/she needed to move.Review of Resident R105's entire clinical record revealed no documented evidence that the resident or resident representative were notified of the room change and subsequent response from the resident or resident representative.Interview with the Director of Nursing, Employee E2, on June 2, 2026, confirmed there was no documented evidence of the room move process/notification 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.
- Potential for harm · D2026-06-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide proper notification to the physician in a timely manner for one of 37 residents reviewed (Resident R26).Findings Include:Review of Resident R26's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2026, revealed the resident has a BIMS (Brief Interview for Mental Status - cognitive assessment) Score of 7 (severe cognitive impairment) and diagnoses of anemia (lack of healthy red blood tissues), osteoarthritis (degenerative joint disease) , and malnutrition (lack of sufficient nutrients in the body). Resident R26 was admitted to the facility on [DATE]. Continued review of Resident R26's comprehensive MDS dated [DATE], revealed the resident required partial/moderate assistance from staff for rolling left/right and sitting to lying.Review of Resident R26's comprehensive care plan revealed the resident…
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 · D2026-06-05 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff and resident interviews it was determined that the facility failed to conduct a complete, accurate, and thorough investigation of alleged abuse and neglect for two of 37 residents reviewed (Resident R37 and R26). Findings Include: Review of facility policy Abuse Prevention/Reporting revised February 25, 2025, revealed the facility will investigate of all suspected cases of abuse. Further review of the facility policy revealed the facility will collect written documentation such as signed witness statements, statements of accused personnel, medical records, incident reports and other pertinent information. Review of Resident R37's quarterly MDS (an assessment of resident needs) dated May 3, 2026, revealed the resident was severely cognitively impaired and diagnosed with obstructive uropathy (blockage in the urinary system). Review of the MDS revealed Resident R37 used a supra pubic catheter for urinating (a tube inserted through a small…
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 before2026-06-05 · 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 review of clinical records, observation, interviews with resident and staff it was determined that the facility failed to provide quality of care in accordance with physician orders for two of 37 residents reviewed (Resident R287 and R78). Findings Include: Review of Resident R287's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of malignant neoplasm of the tongue (tongue cancer) and protein-calorie malnutrition (inadequate intake of protein and calories, leading to loss of fat and muscle). Continued review of Resident R287's clinical record revealed a physician order dated May 24, 2026, to use Infuvite Adult Intravenous (IV) Solution (multiple vitamin) at 80 milliliter/hour (ml/hr) intravenously one time per day. Further review of Resident R287's clinical record revealed a physician order dated June 2, 2026, for Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride - used to maintain fluid and electrolyte balance) administered at 75 ml/hr…
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 before2026-06-05 · 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, review of clinical records, and staff interviews it was determined that the facility failed to obtain a physician order for tracheostomy size for one of one resident reviewed with tracheostomy (Resident R2).Findings:Review of facility policy Tracheostomy Care revealed tracheostomy tubes should be changed as needed or as ordered. Preparation and assessment include checking the physician order. Review of Resident R2's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 1, 2026, revealed the resident was severely cognitively impaired and had a diagnosis of respiratory failure (not enough oxygen passes from your lungs to your blood). Review of Resident R2's MDS revealed the resident received tracheostomy care (a surgically created hole in your trachea that allows for breathing).Review of Resident R2's care plan revised June 11, 2025, revealed the resident had altered respiratory status related, but not limited to, tracheostomy and pulmonary edema.Observations on June 3, 2026, at 12:30 p.m. revealed Resident R2…
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 before2026-06-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards for 1 of 37 residents observed (Resident R287).Findings Include:Review of Resident R287's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of malignant neoplasm of the tongue (tongue cancer) and protein-calorie malnutrition (inadequate intake of protein and calories, leading to loss of fat and muscle).Continued review of Resident R287's clinical record revealed a physician order dated May 24, 2026, to use Infuvite Adult Intravenous (IV) Solution (multiple vitamin) at 80 milliliter/hour (ml/hr) intravenously one time per day.Further review of Reisdent R287's clinical record revealed a physician order dated June 2, 2026, for Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride) administered at 75 ml/hr intravenously every shift for four days.Observations…
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 before2026-06-05 · 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 review of facility policy, observations, and interview with staff, it was determined that the facility failed to implement an effective infection control program related personal protective equipment for one of 37 residents observed (Resident R2).Findings Include: Review of facility policy on personal protective equipment revealed that personal protective equipment appropriate to specific task requirements is available at all times. Further review of facility policy revealed employees required to perform tasks that may involve exposure to blood/body fluids will be provided appropriate protective clothing and equipment. Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Anoxic Brain Damage (when the brain is deprived of oxygen) and Chronic Respiratory Failure with Hypoxia (the lungs cannot supply enough oxygen to the blood). Observation conducted on June 5, 2026, at 9:52 a.m. revealed that an enhanced barrier…
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 · E2025-07-18 · tag F0806 — failed to honor food preferences — patternEnsure 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
Facility failed residents with food preferences.Based on interviews with residents, observations of the food service and a test tray evaluation, interviews with dietary staff, reviews of policies and procedures and reviews of resident council and food committee meeting minutes, it was determined that each resident was not receiving foods and drinks to accommodate their individualized preferences. Appealing food and drink options of similar nutritive value were not being planned and provided on facility menus. (Residents R58, R47, R164, R145, R 207, R208, R220, R77, R117, R196, R64, R194, R144, R219, R86, R50, R234 and R115). Findings include: A review of the facility policy titled resident food committee dated March 2020 revealed that the facility staff were responsible for supporting the food committee established by the residents. The purpose of the residents meeting was to review the menus planned by the Food and Nutrition Department, review special food activities and give the residents a chance to voice concerns about facility food. The policy also said the food service…
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 before2025-07-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and review of facility policy, it was determined that the facility failed to ensure that medications were stored in a safe manner during medication administration. Findings include: Review of facility policy on Medication Storage date March 2020, section Policy Statement revealed that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Under section Policy Interpretation and Implementation #1. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. #2. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. #3. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals unless permitted by the physician. #7. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications…
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 16 citations
- Potential for harm · D2025-07-18 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews with staff, and review of clinical records it was determined the facility failed to obtain laboratory services to meet the needs of one of 38 resident records reviewed (Resident R105). Findings include:Review of Resident R105 clinical records revealed the resident was diagnosed with hypothyroidism (underactive thyroid). Physician orders dated May 14, 2025, instructed a Thyroid stimulating thyroid test (measures the amount of TSH levels in the blood) in five weeks.On July 16, 2025, during an interview with the Unit Manager, Licensed Practical Nurse, Employee E18 stated the doctor has in the progress notes continue to monitor but failed to show the May 2025 order for TSH levels was completed.PA 28 Code 211.12(d)(3)(5) Nursing services.
- Potential for harm · D2024-09-26 · 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 the observations and staff interviews, it was determined that the facility failed to ensure that the residents were treated with dignity and respect for one of four nursing units reviewed (Fourth Floor Main). Findings include: Observation of fourth floor main dining room on September 25, 2024, from 12:00 p.m. to 12:40 p.m. revealed that there were 14 residents in the dining room. It was revealed that there were two residents on table eating the lunch, five other residents on the same table were not served their meals. Two residents who received lunch tray early were finished by 12:30 p.m. while all other residents on the same table were not served. Further observation revealed that cart with trays for other residents arrived at the unit at 12:32 p.m., and were served by 12:35 p.m.11 trays arrived for the rest of 12 residents in the dining room. One resident did not receive the tray until 12:40 p.m. Interview with Nurse Aide, Employee E8, on September 25,2024, from 12:30 p.m stated two of five residents sitting at the center table received the lunch tray around 11:30 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, interview with staff, and review of facility documentation, it was determined that the facility failed to ensure a resident was treated with dignity and respect when staff attempted to provide care for one of 35 residents reviewed (Resident R322). Findings include: Review of a facility reported incident dated August 25, 2024 indicated a 11-7 aide mistakenly thought Resident R322 needed her brief changed and took the covers off the resident without asking. The facility documentation revealed in Resident R322's interview the resident said the aide came over to her bed and pulled the sheets off of her. The resident asked, 'What are you doing.' The resident said the aide stopped and apologized and said I am sorry I just thought you needed to be changed. The resident felt he should have asked first and felt, violated when he took her blankets off without asking. Facility documentation stated the resident said 'He didn't touch me-He thought I wore a brief -He should have asked.' 28 Pa Code 201.18(e)(1)(h) Management 28 Pa Code 201.29 (a)(c)(j)(k)…
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 · D2024-09-26 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission relating to oxygen administration for one of thirty-five residents reviewed. (Resident R99) Findings Include: Review of the facility policy titled, Resident Plan of Care with a revision date of June 2024 states, Policy Statement- Our facility's Care Planning/Interdisciplinary Team is responsible for the development of a plan of care for each resident. Policy Interpretation and Implementation states, The care plan is based on the resident's assessment and is developed by a Care Planning/Interdisciplinary Team. The Interdisciplinary Team, resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development and revisions to the resident's care plan. Review of Resident R99's clinical record revealed the resident was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of facility policies, observations, review of clinical records, and interviews with residents and staffed revealed that the facility failed to ensure resident care plan were revised related to bed rails, beds against the wall, oxygen therapy, and diet for five of thirty-five residents reviwed. (Residents R106, R42, R96, R125, and R574). Findings Include: Review of Resident R106's clinical record revealed the diagnoses of paraplegia (paralysis of the legs and lower body), need for assistance with personal care, pressure ulcer of sacral region- stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), and osteomyelitis (infection in the bone) of vertebra. Interview with Resident R106 on Monday, September 23, 2024, at 11:46 a.m., revealed that she has been requesting bed side rails since she was transferred on second floor unit - 2 Main on September 12, 2024. Per R106's statement - she is paraplegic and bed side rails…
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 · D2024-09-26 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is 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 resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities of daily living was maintained and did not diminish for one of 35 resident records reviewed (Resident R141). Finding include: Review of the facility policy titled, Restorative Therapy effective March 2020, states Restorative Nursing Programs (RNP) will be provided and considered for residents admitted to the facility with restorative needs and who will benefit from a restorative program in conjunction with formalized rehabilitation therapy. The rehabilitation staff will assist with the identification of residents who will benefit from Restorative nursing; work with nursing to identify and design appropriate programs; and provide restorative program training to the Certified Nurse Assistant (aka Nursing Assistant). When a restorative nursing program is established by a therapist, the residents'…
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 before2024-09-26 · 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 the review of clinical record, interview with resident and staff, it was determined that the facility failed to administer the medication in a timely manner as ordered by the physician and according to the professional standards of practice for two of 35 residents reviewed. (Resident R179 and Resident R147) Findings Include: Review of facility policy Administering Medication dated June 2024, revealed Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered one hour before and after the prescribed times. Standard prescribed times will include but not limited to a. Morning Medication b. Afternoon meds c. Early evening meds d. Late evening meds e. Night meds f. Specific prescribed medication times Interview with Resident R147 on September 23, 2024, at 10:24 a.m. stated he received the medication often late; he stated sometimes the medications that needed to be taken with meals and medications that needed to be taken before meals were not given timely. He stated sometimes his morning medication which he usually takes…
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 before2024-09-26 · 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, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure physician orders were followed in relation to oxygen administration for one of thirty-five residents reviewed. (Resident R98) Findings Include: Review of facility policy titled, Oxygen Administration- Resident with a revision date on December 2022 states, Purpose- The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the procedure state, . 4. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate ordered. 5. Place appropriate oxygen device on the resident. 6. Adjust the oxygen delivery device so that it is comfortable for the resident. 7. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. 8. Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened. 9. Observe the resident upon setup and periodically thereafter to be sure oxygen is tolerated. Review 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 · D2024-09-26 · 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
Based on clinical record review and facility policy, it was determined that the facility failed to ensure the timely availability of medication for one of 35 residents reviewed (Resident R12). Findings include: Review of the facility policy titled Pharmacy Services effective March 2020 states, The facility shall accurately and safely provide or obtain pharmacy services including the provision of routine and emergency medication and biologicals and the services of a licensed Pharmacist. The same policy states, The facility shall contract with a licensed Pharmacist to help obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet the state and federal requirements. Review of Resident R12's physician orders indicated Ativan gel 0.5mg/ml be applied to the resident three times a related to the resident's diagnosis of anxiety disorder. Review of Resident R12's nursing progress notes and the medication administration record revealed the Ativan gel was not administered due to pharmacy services as…
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 before2024-09-26 · 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
Based on observations and staff interviews, it was determined that the facility failed to implement an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during dining services for one of four nursing units reviewed (Fourth Floor Main). Findings Include: Observation of fourth floor main dining room on September 25,2024, from 12:32 p.m. revealed that there were 14 residents in the dining room. Five employees were serving lunch to residents in the dining room. It was observed that Employee E8, Nurse Aide, passed tray to a resident sitting at the table, set up the tray, opened the utensils, touched residents clothing protector and table and proceeded to pass and set up the lunch tray for the next residents. There was no hand hygiene observed during the lunch service. Further observation revealed that Employee E8 was sitting next to a resident started helping the resident in front of her with utensils, drinks, and setting up the tray. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · 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 a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for four of four months of antibiotic stewardship program data reviewed. (May 2024, June 2024, July 2024 and August 2024). Findings Include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements 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.
- Potential for harm · D2024-09-26 · tag F0924 — isolatedPut firmly secured handrails on each side of hallways.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for one of four nursing floors observed (Fourth Floor Main). Findings include: Observation of the corridor handrail revealed that the following corridor handrails were loose/not secured properly, -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER], -near resident room [ROOM NUMBER], -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] -near resident room [ROOM NUMBER] Observation of the corridor handrail revealed that the following corridor handrails were detached off the wall. - next to attic access wall next to room [ROOM NUMBER] towards the nurses station. -next 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.
- Potential for harm · E2024-04-24 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records for eight of 10 records reviewed (Resident R2, R3, R4, R5, R6, R7, R8, R10). Findings include: Review of the April 2024 Treatment Administration Record (TAR) documentation for resident R2 revealed that an order to Check placement of [NAME]-chip (a wearable tracking device designed to prevent cognitively impaired residents from wandering from designated, staff monitored areas) to right ankle .every shift for elopement, ordered on March 21, 2024, had not been signed off as completed on day shift on April 16 and 22, on evening shift on April 1-3, 5-8, 10-12, 15-17, 19, and 20, or on night shift on April 1, 5, 7-10, 12, 15, 17, and 22. Review of the April 2024 TAR documentation for Resident R3 revealed that an order for Silvadene External Cream 1% (a cream prescribed for wound healing) .apply to left gluteal fold topically every day shift, ordered on March 26, 2024, 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 · D2024-01-09 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was distributed, and served in accordance with professional standards for food service safety. Findings include: A review of facility policy titled, Food Temperature effective date March 2020, indicated that all time/temperature control for safety food must maintain an internal temperature of 41 F (Fahrenheit) or lower or 135 F or higher while being held for service. On January 9, 2023 at 12:09 p.m an interview and tray testing was conducted and confirmed with the Food Service Director (FSD), Employee E4 who confirmed the following food temperatures at the time of serving: BBQ Pork Riblettes- 120.2 degrees Fahrenheit (F) Brussel Sprouts- 125.8 F Boiled New Potatoes- 127 F Juice -49 F . It further revealed during the interview with FSD that serving temperatures should be 135 F or above for hot foods and for cold food 41 F per facility policy. On January 9, 2023, at 12:26 p.m. an interview with Resident R5 revealed food temp sometimes it's warm…
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 · E2023-12-01 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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, interviews, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: Observations during the initial tour of the 2 Main nursing on November 28, 2023, at 11:35 a.m. in room [ROOM NUMBER], bed A revealed Resident R93 laying in bed with a fly buzzing around his head while attempting to interview him. Observations during the initial tour of the 2 Main nursing on November 28, 2023, at 11:45 a.m. in room [ROOM NUMBER], bed B revealed Resident R23 sitting up in her bed waving her hand at a fly buzzing around her. An interview on November 28, 2023, at 11:45 a.m. in room [ROOM NUMBER], bed B with Resident R23, who stated that the flies are common and this one is really bothering her. Observations on November 28, 2023, at 12:00 p.m. at the 2 Main nurse station revealed a fly buzzing around the desk. An interview on November 28, 2023, at 12:00 p.m. at the 2 Main nurse station with the unit manager, Employee…
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.
- No harm found · C2026-06-05 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation and staff interview it was determined that the facility failed to include active input from residents, their representative(s), family members, and representatives of direct care staff in the facility assessment process.Findings Include: Review of facility documentation titled, Facility Assessment dated April 22, 2026, states the people involved in the process are the Administrator, Director of Nursing, Governing Body Rep, and the Medical Director. Review of the facility assessment and the sign-in sheet for individuals involved in completing the annual review of the facility assessment on April 22, 2026, revealed no documented evidence that the facility included input from residents/resident representatives, or active involvement from direct care staff (including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Nurse Aides (NA), input from resident.Interview on June 5, 2026, at 1:00 p.m. with Nursing Home Administrator, Employee E1, confirmed no documentation was available to support evidence of active…
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.
- 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
No federal fines in the current CMS record.
Part of a chain
This home belongs to CENTER MANAGEMENT GROUP — 16 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 | 1 of 5 | 3.2 | -2.2 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 1 of 5 | 4.3 | -3.3 vs chain |
The other 15 homes this chain runs (chain average 3.2★, 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 | Since |
|---|---|---|---|
| BOEHM, CAROLINE | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/28/2023 |
| GROS, CHARLES-EDOUARD | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/28/2023 |
| GREYSTONE FUNDING COMPANY LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | since 07/30/2024 |
| ALLEN, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/03/2014 |
| BAUER, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/15/2019 |
| PETROSKI, EDWARD | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/08/2018 |
| KLEIN, BARUCH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/03/2014 |
| LEVI, SHLOMO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| MARASCO-KENNEDY, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/18/2019 |
| PEARLSTEIN, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/18/2016 |
CMS files one row per role, so the 22 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M 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
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
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 395282. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-05, 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 →
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