Brookmont Healthcare And Rehabilitation Center
510 Brookmont Drive, Effort, PA 18330 · For profit - Corporation · 119 certified beds · (610) 681-4070 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
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 improved from 2 to 4 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 | 7.7% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.8% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 25.9% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.3% | 0.2% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 0.3% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.3% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.6% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.9% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.3% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 45.7% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.9% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.5% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.69 | 1.62 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.54 | 1.18 | 1.80 | better |
§ 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.
52.8% 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 332 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.7% 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 115 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.8%CMS range 46.9–60.4 | 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 | 9.2%CMS range 7.2–12.0 | 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 | 68.7% | 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 | 65.2% | 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 | 56.5% | 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 | 69.5% | 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 | 22.7% | 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 | 29.0% | 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 | 0.0% | 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 | 1.2% | 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 | 7.5%CMS range 5.3–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 119 beds and averages 111.9 residents a day — about 94% occupied, or roughly 7 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 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 2.79 hrs/resident/day on weekends vs 3.45 on weekdays — 19% thinner on weekends. RN hours go from 0.68 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · E2025-12-19 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of selected facility policies, clinical records, and staff interviews, the facility failed to show documented clinical justification for the administration of psychoactive medications for two residents out of five sampled residents for unnecessary medication prescribing practices (Residents 5 and 18).Findings included: A review of a facility policy entitled Psychotropic Medication Use last reviewed by the facility August 6, 2025, indicated that residents do not receive psychotropic medications that are not clinically indicated (a written explanation of why a medication is needed) and necessary to treat a specific condition documented in the medical record. The policy defined psychotropic medication as any medication that affects brain activity associated with mental processes and behavior. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless contraindicated, to determine whether the continued use of the medication in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, clinical record review, select policy review, and staff interviews, it was determined the facility failed to ensure the resident environment remained free from potential accident hazards for one resident (Resident 10) of 24 sampled residents when medications were left accessible at the bedside without documented clinical assessment for safety or authorization to self-administer.Findings included: A review of a facility policy titled Medication Policy, last reviewed August 6, 2025, revealed medications are to be administered by licensed nurses, or by other legally authorized staff to do so, as ordered by the physician and in accordance with professional standards of practice in a manner that prevents contamination or infection. The policy also stated the licensed nurse will observe resident consumption of medication. This was listed as number 16 in the policy explanation and compliance guidelines. A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with…
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 before2025-12-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 a review of clinical records and select facility policy, and staff interviews, it was determined the facility failed to monitor a resident's weight and timely identify significant weight loss and assure timely assessment of a resident's nutrition status to timely develop and implement nutritional approaches addressing significant weight and notify a resident's attending physician and responsible party of significant weight loss for one resident out of four residents sampled for nutrition (Resident 9). Findings included: A review of a facility policy entitled Weight Assessment and Intervention last reviewed August 6, 2025, indicated any weight change of five percent (5%) or more since the last weight assessment will be retaken for confirmation. The Dietitian will review the Weight Records and negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change had been met. The threshold for significant unplanned and undesirable weight loss will be based 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.
- Potential for harm · D2025-12-19 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure the availability of required emergency dialysis supplies and failed to provide person-centered care related to hemodialysis for one resident out of two residents reviewed who received hemodialysis (Resident 88).Findings include: According to the National Kidney Foundation, individuals receiving hemodialysis, (a life-sustaining treatment for individuals with kidney failure that removes waste and excess fluids from the blood) must have access to emergency supplies, such as clamps and pressure dressings, in the event of complications such as hemorrhage (bleeding) or catheter dislodgement. A review of the policy Care of Resident with End-stage Regal Disease last reviewed August 6,2025, indicated that staff caring for residents with ESRD ( End Stage Renal Disease) including residents receiving dialysis care outside of the facility shall be trained in the care and special…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-19 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that necessary behavioral health care and services were provided to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents reviewed for behavioral health needs (Resident 94). Findings include: A review of Resident 94's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including a personal history of suicidal behavior (defined as documentation of past suicidal actions or attempts, indicating increased risk for future suicidal thoughts or behaviors and the need for clinical monitoring). Further review of Resident 94's clinical record revealed a history and physical from the hospital prior to admission to facility dated [DATE], indicating he had been admitted to the hospital due to being found by a family member with self-inflicted lacerations to the left wrist and scissors present in the bed. The resident denied suicidal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-28 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records, and staff interview it was determined the facility failed to timely identify significant weight loss and monitor resident's weights consistently and accurately to timely identify changes in nutritional parameters and timely implement nutritional interventions for two of 24 residents sampled. (Residents 72 and 27) Findings include: Review of the facility Weight Monitoring Policy last reviewed March 2024 indicated the facility will ensure all residents maintain acceptable parameters of nutritional status. Information from the nutritional status and dietary standards are used to develop an individualized care plan. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month- 5% weight loss is significant; 3 months- 7.5% weight loss is significant; 6 months- 10% weight loss is significant. A review of Resident 72's clinical record revealed admission to the facility on September 21, 2022, with…
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 before2025-02-28 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 select facility policies and clinical records and staff interview, it was determined the facility failed to administer pain medication as prescribed by the physician on an as needed basis for one of 24 residents reviewed. (Resident 10). Findings include: A review of the facility policy entitled Pain Assessment and Management last reviewed March 2024, indicated the purpose of the procedure is to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Review of Resident 10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include post-surgical care for fracture of right tibia (leg bone), acute pain due to trauma, and hypertension. A review of current physician orders revealed that Resident 10 was prescribed pain medications based on a pain scale to guide appropriate administration. The pain scale categorizes pain levels as mild…
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 before2025-02-28 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to implement procedures to ensure accurate documentation of the disposition of controlled medications upon discharge for one (1) of three (3) discharged residents reviewed (Resident 109). Finding include: Review of Resident 109's clinical record revealed the resident was admitted to the facility on [DATE], and was discharged to the hospital on November 27, 2024. Review of controlled substance receipts indicated that 30 tablets of Tramadol 50 mg (dispensed as half tablets, totaling 60 tablets of 25 mg each) were delivered to the facility on November 21, 2024, for Resident 109. Review of the Medication Administration Record (MAR) for November 2024 documented the resident was administered three (3) doses of Tramadol during the month. Further review of the resident's closed record revealed no documentation of the disposition of the remaining 57 tablets of Tramadol 25 mg at the time of the resident's discharge 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 · E2024-05-23 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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, clinical record review and staff and resident interviews it was determined that the facility failed to provide care in a manner that maintains the personal dignity, respect, and quality of life of seven residents out of 17 sampled (Resident 3, 4, 7, 9, 11,12, 16). Findings include: A review of Resident 11's clinical record revealed the resident was admitted to the facility April 11, 2024, with diagnoses which included type 2 diabetes and muscle weakness. An interview with Resident 11 on May 23, 2024, at 9:10 AM revealed that the resident stated that staff do not answer call bells timely. The resident stated that on a good day the staff will answer the call bells in 30 minutes. The resident stated that it can take up to two hours for staff to answer his call bell. The resident further explained that he was in the bathroom recently and rang for staff because there was no toilet paper left in the bathroom. The resident stated it took 25 minutes for a staff member to come in and ask what he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on May 23, 2024, at approximately 9:00 AM revealed a strong urine smell when entering the facility. An observation on May 23, 2024, at 9:10 AM revealed a strong urine smell emanated from resident room [ROOM NUMBER]. There were gouges in the paint on the wall behind the residents' beds. Paper and debris was observed on the floor. A used glucose monitoring strip was observed lying on the baseboard heater. The light at the first bed did not turn off. The light switch was broken and does not turn the light off. The handle was broken off the nightstand. An observation on May 23, 2024, at 9:26 AM, in the Nourishment Room in the Center Hallway revealed the hinges broken off the cabinet door. An observation on May 23, 2024, at approximately 10:00 AM revealed 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.
Show the remaining 19 citations
- Potential for harm · Dcited before2024-05-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interviews, it was determined that the facility failed to develop person-centered care plans that addressed a resident's medical needs and prescribed medication therapy for one resident out of 17 sampled residents (Resident 13). Findings include: A review of the clinical record revealed Resident 13 was admitted to the facility April 29, 2024, with diagnoses of type two diabetes (a condition from insufficient production of insulin causing high blood sugar), sarcoidosis (a condition where there is an abnormal collection of inflammatory cells that form clumps in the skin or lymph nodes that result in dry cough and shortness of breath), and long-term use of anticoagulants (blood thinning medication) and insulin (injectable medication to treat diabetes). A review of a physician order initially dated April 29, 2024, revealed that the resident was receiving Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/milliliter (ml) inject 17 unit subcutaneously in the afternoon for diabetes and Apixaban (Eliquis) Oral Tablet 5 milligrams (mg) give…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-23 · 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 select facility policy, observation, and staff interview, it was determined that the facility failed to ensure adherence to medication expiration/use by dates for one of 15 residents (Resident 15) and failed to properly label medication in one of five medication carts (Center Cart). Findings include: A review of facility policy entitled Storage of Medications indicated that the pharmacy dispenses medications in containers that meet legal requirements including standards established, medications are maintained in the dispensed packaging. Medications outdated are disposed of according to disposal guidelines. A review of facility policy entitled Medication Administration indicated that the individual administering medications must verify the resident's identity before giving the medication verifying the name and date of birth , checking identification band, checking photograph and medical record. The manufacturer's expiration/beyond use date on the medication label must be checked prior to administering.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0574 — patternThe resident has the right to receive notices in a format and a language he or she understands.
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, select facility policy CMS guidance and facility documentation, and resident, resident representative, and staff interviews, it was determined that the facility failed to ensure that resident Medicare beneficiaries were only disenrolled from Medicare health plans with the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding for four out of the 23 residents sampled (Residents 82, 95, 168, and 269). Findings include: A review of a CMS guidance titled Memo to Long Term Care (LTC) Facilities on Medicare Health Plan Enrollment dated October 2021 revealed CMS continues to hear reports of the unacceptable practice of nursing facilities or skilled nursing facilities (collectively, long-term care or LTC facilities) disenrolling beneficiaries from Medicare health plans (Medicare Advantage plans with and without Part D, Medicare-Medicaid plans, or Programs of All-Inclusive Care for the Elderly (PACE) without the beneficiary's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on April 2, 2024, at 11:10 AM , in resident room E-58 revealed multiple dark brown water stains in the bowl of bathroom toilet. Interview with Resident 33, a cognitively intact resident with a BIMS score of 13 (BIMS-brief interview to assess cognitive status. A score of 13-15 indicates intact cognitive responses), indicated that the previous housekeeper used a special cleaner to remove the stains, but the new housekeeper does not use the same cleaner and the toilet looks dirty all the time. Further observation of resident room E-58, bed A, revealed light brown stains on the Resident 33's fitted sheet and a yellow stain on the pillowcase. Resident 33 stated that he makes his bed every day. He also stated that his bed linens are the same sheets since I came back (from the Covid isolation room). I've been back over a month. 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 · Ecited before2024-04-05 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 clinical record review and staff interviews, it was determined that the facility failed to develop person-centered care plans that addressed a resident's medical needs for one resident (Resident 82) and prescribed medication therapy for three residents out of 23 sampled residents (Resident 48, 80, and 53). Findings include: A review of the clinical record revealed Resident 82 was admitted to the facility January 24, 2024, with diagnoses of viral hepatitis C without hepatic coma, and cirrhosis of the liver. A review of Resident 82's care plan, conducted during the survey ending April 5, 2024, revealed that the resident's comprehensive care plan did not include the resident's medical condition, viral hepatitis or cirrhosis of the liver and the necessary care and services necessary to manage those conditions. Interview with the Director of Nursing (DON) on April 5, 2024, at approximately 9:10 AM, confirmed the absence of Resident 82's medical condition, viral hepatitis, and cirrhosis of the liver, on his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate consistent monitoring and thorough assessment of one resident displaying constipation (Resident 116) and by failing to follow physician orders for bowel protocol prescribed for two residents out of 23 sampled (Residents 36 and 48) to promote normal bowel activity to the extent practicable. 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). According to the American Nurses Association Principles for Nursing Documentation, nurses document their work…
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 · E2024-04-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview, it was determined that the facility failed to implement individualized approaches to restore normal bladder function to the extent possible and provide maintenance incontinence care for two out of 23 sampled residents (Resident 36 and 64). Findings include: A review of Resident 36's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and epilepsy (seizure disorder). A review of the resident's plan of care for mixed bladder incontinence related to disease process revealed an intervention dated January 5, 2024, for the resident to have a scheduled toileting program for bowels only. The resident was to be toileted between 8:00 AM and 8:30 AM, 11:00 AM and 11:30 AM, 2:00 PM and 2:30 PM, 6:00 PM and 6:30 PM, 10:00 PM and 10:30 PM, and 11:30 PM and 12:00 AM. A review of the documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
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 select facility policy, and a staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one out of the 23 residents sampled (Resident 23). Findings include: A review of facility policy titled Pain Assessment and Management, last reviewed by the facility on March 25, 2024, revealed that it is the facility's policy to identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. The policy indicates that non-pharmacological interventions for managing residents' pain may be appropriate alone or in conjunction with medications. Also, the policy indicates that pharmacological interventions (i.e., analgesics medications) may be prescribed to manage pain; however, they do not usually address the cause of the pain and can have adverse effects on the resident. A clinical record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of select facility policy and controlled drug shift count records, observations, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on three of five medication carts (Center, North, and West). Finding include: A review of the facility policy Controlled Substances last reviewed by the facility March 25, 2024, indicated that nursing staff must count controlled medications at the end of each shift. The nurse coming on duty, and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. A review of the Inter Shift Drug Record sheet for April 2024, for the Center medication cart on April 3, 2024, at approximately 8:57 AM, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the task to count the controlled drugs in the respective medication cart April 1, and 2, 2024. Interview with Employee 1 (LPN), on April 3,…
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 · E2024-04-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations of the resident pantry areas, review of select facility policy, and staff interview, it was determined that the facility failed to maintain a sanitary environment and acceptable practices for the storage and service of food to prevent the potential for microbial growth in foods and conditions, which increased the risk of food-borne illness in two of two resident pantry areas. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of the facility policy titled Foods Brought by Family/Visitors last reviewed 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.
- Potential for harm · D2024-04-05 · 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 observation, a review of clinical records and interviews with staff it was determined that the facility failed to consistently provide a functional communication system to maintain the resident's ability to communicate for one of one resident sampled with communication needs/deficit (Resident 318). Findings include: A review of Resident 318's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia, depression, and anxiety. A review of Resident 318's nursing progress notes revealed a nursing note dated March 29, 2024, at 10:21 PM, indicating that the resident's first language is Spanish. Further review revealed that the resident exhibited increased agitation and was approached by several staff members who were unable to redirect her behaviors. A Spanish speaking nurse approached resident, engaged her in conversation, and eventually was able to calm the resident down. The nurse encouraged the resident to take her medications with coffee at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-05 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a history of trauma for one out of 23 residents reviewed (Resident 23). Findings include: A clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 26, 2024…
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 before2024-04-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, a review of select facility policy, and staff interview, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medication on one of three medication carts observed (Center medication cart - Resident 40). Findings include: A review of facility policy entitled Administering Medications last reviewed by the facility March 25, 2024, indicated the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Observation of medication administration pass beginning at approximately 8:47 AM, on April 3, 2024, revealed Employee 1, Licensed Practical Nurse (LPN), on the center hall medication cart. One (1) Lantus Solostar (medication used for diabetes) belonging to Resident 40, was observed to be opened and available for use but not dated when initially opened. Employee 1, licensed practical nurse (LPN), confirmed the medication belonged to Resident 40, and that the insulin was not dated when first…
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 · D2024-04-05 · 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 observation and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection during the medication administration for one out of two residents observed (Resident 170) and one of three medication administration carts (center hall) sampled. Findings include: Observation of medication administration pass beginning at approximately 8:45 AM, on April 3, 2024, revealed Employee 1, Licensed Practical Nurse (LPN), on the center hall medication cart. Employee 1 was observed in the process of administering medications to Resident 170, who resided, in room [ROOM NUMBER]-B. The resident had a physician order dated March 22, 2024, for Mucinex (an expectorant medication to help loosen congestion) oral tablet extended release 12 hour, 600 milligram (mg), give 1 tablet by mouth every 12 hours for congestion. Employee 1, LPN, removed the medications from the medication cart. After removing the 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.
- Potential for harm · Ecited before2023-11-08 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide person-centered care for diabetes management and medication administration and blood glucose monitoring for one resident out of four sampled (Resident A1). Findings include: A review of the clinical record revealed Resident A1 was admitted to the facility on [DATE], with diagnoses to include diabetes. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 15, 2023, revealed that the resident was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). During interview with Resident A1 on November 8, 2023, at 12:30 PM the resident stated that at times she receives her Metformin medication (anti-diabetic medication) late in the morning and that her morning blood glucose check…
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 · E2023-11-08 · tag F0807 — failed to offer suitable drinks — patternEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review and staff and resident interview it was determined that the facility failed to provide drinks consistent with resident needs and preferences for four out of seven residents sampled (Residents B1, B2, B3, and A1). Findings include: Observation on November 8, 2023, at approximately 10 A.M., Resident B1, a cognitively intact resident, was observed in her room, seated in her wheelchair. Resident B1's roommate, Resident B2, a cognitively intact resident, was in her room, lying in her bed at the time. Interview with both residents at that time revealed that these residents expressed concerns that during the 11 P.M. to 7 A.M. shift, nursing staff passes water to them, but then they often do not receive fresh water during the 7 A.M. to 3 P.M. and the 3 P.M. to 11 P.M. shifts. Both residents stated that they are often thirsty and would like fresh water provided to them on each shift of nursing duty. An observation at the time of the interview revealed that each resident's water cup was empty. An interview November 8, 2023 at approximately 10:30…
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 · D2023-11-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and resident and staff interviews it was determined that the facility failed to accommodate residents' need for ready access to the call bell system to request staff assistance for one resident (Resident B1) and timely accommodation of the residents' needs for assistance in accordance with the residents' needs out of seven sampled. (B1 and B2). Findings include: Observation on November 8, 2023, at 10:00 a.m. revealed that Resident B1, a cognitively intact resident, was seated in her wheelchair at the end of her bed, next to the closet. The resident's call bell was clipped behind her bed and was not within reach of the resident. The resident was dressed in a hospital gown and had no socks on her feet. There was an overbed table in front of her. Her bare feet were observed resting on the metal bar at the bottom of the overbed table. During an interview at the time of the observation, Resident B1 stated that her nurse aide had cleaned her, dressed her and placed her out of bed into her wheelchair. The resident stated that her socks were on her bed when the nurse…
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 before2023-11-08 · tag F0574 — isolatedThe resident has the right to receive notices in a format and a language he or she understands.
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 facility documentation and staff interview, it was determined the facility failed to provide information orally and in writing regarding changes in Medicare eligibility and coverage in a language and format the resident understood for one of four reviewed (Resident CR1). Finding include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE] with diagnoses which included an acute myocardial infarction (heart attack). An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated October 4, 2023, revealed that the resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). Upon admission the resident's primary insurance payer was noted to be a Medicare Advantage plan. On October 1, 2023, the primary insurance payer 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.
- No harm found · B2024-04-05 · tag F0622 — patternNot 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for five residents out of 23 residents sampled with facility inititiated transfers (Residents 29, 46, 64, 80, and 269). The findings include: A review of Resident 29's clinical record revealed that the resident was transferred to the hospital on October 1, 2023, and returned to the facility on October 4, 2023. A review of Resident 80's clinical record revealed that the resident was transferred to the hospital on October 11, 2023, and returned to the facility on October 15, 2023. A review of Resident 46's clinical record revealed that the resident was transferred to the hospital on February 23, 2024, and returned to the facility on February 29, 2024. A review of Resident 64's clinical record revealed that the resident was transferred to the hospital on February 25, 2024, and returned to the facility on February 28, 2024. A review of Resident 269's clinical record revealed 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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DIAMOND HEALTHCARE AT BROOKMONT LLC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2023 |
| FRANKEL, YOSEF | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 50% | since 03/01/2023 |
| KURLAND, BENJAMIN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 30% | since 03/01/2023 |
| RUBIN, ISAAC | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 03/01/2023 |
CMS files one row per role, so the 5 rows in the source record cover these 4 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.
This home reported $520K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395462. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, 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.