Highland Manor Rehabilitation And Nursing Center
750 Schooley Avenue, Exeter, PA 18643 · Non profit - Corporation · 120 certified beds · (570) 655-3791 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $19,760 in federal fines (most recent 2023-11-14)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 fell from 3 to 2 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 | 25.1% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.1% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.7% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 29.3% | 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 | 28.7% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.1% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.3% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.7% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.2% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.2% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.9% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.2% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.14 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.20 | 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.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 211 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 100 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.1%CMS range 39.0–49.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.7%CMS range 10.3–16.8 | 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 | 65.0% | 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 | 67.0% | 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 | 62.0% | 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 | 85.2% | 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 | 92.7% | 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 | 98.0% | 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 | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.4% | 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 | 8.0%CMS range 5.2–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 120 beds and averages 109.6 residents a day — about 91% occupied, or roughly 10 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.33 hrs/resident/day on weekends vs 3.69 on weekdays — 10% thinner on weekends. RN hours go from 0.67 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.
- Actual harm · G2024-01-10 · 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 an observation, review of clinical records, select facility policy and fall incident reports, and staff interviews, it was determined that the facility failed to consistently implement, and evaluate the effectiveness, of planned individualized fall prevention measures and provide sufficient staff supervision at the level and frequency required, of residents identified as at high risk for falls and known unsafe behaviors to prevent falls resulting in serious injuries, a fractured femur, for one resident (Resident 98) and a fractured neck for one resident (Resident 56), and failed to provide necessary assistance devices and assure that the resident's environment was free of potential accident hazards to prevent a fall and injuries, abrasions and bruises, to one resident (Resident 39) out of nine residents sampled for accidents. Findings include: A review of the facility policy titled Managing Falls and Fall Risk, last reviewed by the facility on January 2, 2024, indicated that it is the facility's policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-27 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, and staff interview, it was determined the facility failed to ensure licensed nursing staff possessed and demonstrated the appropriate competencies and skill sets to safely assess, manage, and provide care for residents requiring a coude catheter (a specialized urinary catheter with a curved tip used for residents with urinary obstruction and enlarged prostate) for 5 of 5 licensed nurses reviewed (Employees 1, 2, 3, 4, and 5).Findings include: Review of the clinical record revealed Resident 9 was admitted to the facility on [DATE], with diagnosis to include retention of urine (the inability to completely empty the bladder or the complete inability to pass urine) and benign prostatic hyperplasia with lower urinary tract symptoms (noncancerous enlargement of the prostate gland causing urinary obstruction and impaired bladder emptying). Review of a care plan dated March 30, 2026, revealed Resident 9 required the use of a coude catheter. Review of 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 · D2026-05-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure a Licensed Practical Nurse (LPN) timely monitored, recognized, communicated, intervened, and obtained appropriate supervisory assistance when a resident experienced a blocked indwelling urinary catheter (a flexible sterile tube inserted into the urinary bladder to drain urine) for one of 10 residents reviewed (Resident 9).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment 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 · Ecited before2025-09-11 · 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 and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in the facility laundry department and the second hallway ice machine. Findings include: An observation of the second hallway, resident unit ice machine, located in the hallway was noted with no airgap. An air gap is defined as the unobstructed vertical space between the end of a water supply or drainage pipe and the flood level of a fixture or drain. In an ice machine, the air gap prevents contaminated water from backing up into the potable (drinkable) water supply or the ice that residents consume. The importance of the air gap is to prevent cross-contamination, which occurs when dirty water or substances can enter and contaminate clean water or ice. Without an air gap, residents are at risk of exposure to harmful bacteria or other contaminants.Water was observed draining directly into the floor drainpipe. The floor underneath the drainage pipe, extending from the front of the ice machine to the drainpipe, contained a thick layer of sticky black…
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 before2025-06-18 · 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 a review of clinical records, resident grievances, observations, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance for 5 residents out of 10 sampled. (Residents CR1, 2, 3, 4, and 5). Findings include: A review of a grievance filed with the facility by the daughter of Resident CR1, dated April 9, 2025, revealed that Resident CR1 had a bowel movement in her brief and required staff assistance for hygiene care. She activated her call bell at 9:41 AM requesting assistance. Facility records indicated that by 11:41 AM no staff had responded to the call bell, and as of 12:00 PM she remained unchanged. Resident CR1 was ultimately provided incontinence care at 12:30 PM, approximately three hours after her initial request for assistance. The grievance documentation indicated the daughter informed the nurse on duty,…
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 · D2024-12-19 · 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 a review of select facility policy, clinical records, information submitted by the facility, select investigative reports, and staff interviews, it was determined the facility failed to conduct a thorough investigation into an injury of unknown origin (a fractured humeral neck) for one resident out of 24 sampled (Resident 23). Findings include: A review of facility policy titled Abuse Prevention Policy and Procedure, last reviewed by the facility on January 2, 2024, revealed it is the facility policy that an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, then the administrator will assign the investigation to an appropriate individual. The policy indicates the information to be collected includes a review of all events leading up to the incident, a review of the resident's medical record to determine events leading up to the incident, and interviews with staff members on all shifts who have had contact with the resident at the time 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 · D2024-12-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews, it was determined the facility failed to implement a person-centered fall and injury prevention plan of care for one resident out of 24 sampled (Resident 104). Findings include: A clinical record review revealed Resident 104 was admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure (a condition that occurs when the lungs can't exchange enough oxygen and carbon dioxide with the body, making it difficult to breathe). Further clinical record review revealed Resident 104 was at risk for falls and injury related to decreased mobility, medications, and history of falls with a care plan initiated on November 21, 2023. Interventions in place to protect Resident 104 from injury included bilateral fall mats on the sides of the bed initiated on December 13, 2024. A progress note dated December 13, 2024, at 4:15 AM revealed Resident 104 rolled out of his bed and was found on the floor. He was assessed and did…
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 · D2024-12-19 · 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 observation, review of clinical records, and resident and staff interviews it was determined the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for a medical treatment that manages chronic lung conditions and promotes lung capacity and recovery for one resident (Resident 15) out of 24 sampled residents. Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing…
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 before2024-12-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to prevent the development of a pressure injury for one resident out of 24 sampled residents (Resident 26). Findings included: A clinical record review revealed Resident 26 was admitted to the facility on [DATE], with diagnoses that included dementia (a syndrome characterized by a decline in cognitive function severe enough to interfere with daily life), muscle wasting (loss of muscle leading to its shrinking and weakening) and history of a left femoral neck fracture (a break in the upper part of the thigh bone). A review of the resident's person-centered plan of care, initiated on May 2, 2024, identified that Resident 26 was at risk for skin breakdown as evidence by impaired skin sensation, incontinence, and limited mobility with a resident goal to demonstrate no signs or symptoms of skin breakdown. Planned interventions included float heels while in bed, weekly skin assessments by a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · 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 clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 33) of 24 residents reviewed. Findings include: A review of the clinical record revealed that Resident 33 was admitted to the facility on [DATE], with diagnoses to include low back pain and muscle weakness. A review of Resident 33's physician orders revealed the following orders: Tramadol 50mg (narcotic pain medication) give one tablet by mouth every six hours as needed (PRN) for pain initially dated November 20, 2024, and discontinued November 22, 2024. Oxycodone 5mg (narcotic pain medication) give one tablet by mouth every six hours as needed (PRN) for moderate to severe pain initially dated November 22, 2024, and discontinued November 29, 2024. Tramadol 50 mg give one tablet by mouth every 6 hours as needed for moderate to severe pain…
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 · D2024-12-19 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 24 residents sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], and had diagnoses which included major depressive disorder and schizophrenia (a mental health condition that is marked by symptoms such as hallucinations and delusions). A review of an October 2024 Consultant Pharmacist Medication Regimen Review revealed the consultant pharmacist indicated the resident's order for Abilify 10 MG (antipsychotic medication) was to be reviewed for a gradual dose reduction. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed…
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 22 citations
- Potential for harm · Ecited before2024-10-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, 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 October 8, 2024, at approximately 9:45 AM, revealed the following: The shower room in the 200 hall was noted to have a black substance built-up on the caulking around the shower. room [ROOM NUMBER] was noted to have water damage to the ceiling. Old brown water stains were seen along with a black mold like substance. A bath blanket was noted on the floor with dried brown water stains on it. Further, there was a dead earwig (bug that is attracted to moisture) on the bath blanket. A bedside table was noted to be cracked and chipped. [NAME] spots and streaks were noted on the wall next to the nightstand. The molding was peeling off the wall. The center hallway had water damage to the ceiling. Brow stains were noted on the ceiling and a piece of plywood was screwed to the ceiling covering a hole.…
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 before2024-03-06 · 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
Based on review of minutes from the Residents' Council meeting and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life, by failing to respond timely to residents' request for assistance as evidenced by experiences reported by five residents out of five sampled (Residents 14, 11, 9, 13 and 10 ). Findings include: During interviews conducted throughout the day tour of duty on March 6, 2024, the residents stated that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests for assistance, including untimely responses to their requests via the nurse call bell system. A review of minutes from the Residents' Council meeting on February 1, 2024, revealed that Resident 14 was requesting staff assignments be reassessed as he has been left in the bathroom for long periods of time when his assigned aide is off the floor. He reported that staff tell him they do not have him on their assignment and do not…
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 · E2024-03-06 · 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, review of clinical records and select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure fresh water was consistently readily accessible to residents to promote adequate hydration, resident preference and comfort for five out of 14 residents reviewed (Residents 11, 9, 12, 13, and 2). Findings include: A review of the facility policy titled Water Pass provided by the facility on March 6, 2024, indicated that the facility will provide the residents with fresh water every shift and that straws, cups, and lids are changed at a minimum of every three days. During an interview with Resident 11 on March 6, 2024, at 10:43 AM, the resident expressed frustration that she has to consistently ask staff to provide fresh drinking water, and staff do not routinely provide fresh drinking water daily. She stated you have to ask for it, and even then, they're so busy, they forget. My son got me a cup yesterday, but no staff member has been in to give me any (fresh water) since then. During an interview with Resident 9 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 · F2024-01-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and staff interviews it was determined that the facility failed to maintain infection control practices during medication administration on one out of two medication carts (Station A, Back Hall), failed to maintain ice machines and ice distribution areas in a sanitary manner on two of two resident units and failed to maintain the facility's laundry area in a clean and sanitary manner. Findings include: Observation of medication administration pass, on January 7, 2024, at approximately 10:05 AM, revealed Employee 1, Registered Nurse (RN), on the Station A, Back Hall, medication cart. During the medication pass observation, the surveyor observed an open, purple can Monster energy drink, on the top left side of the medication cart. Additionally, a dark colored, winter jacket was draped over the rear, right side of the medication cart. Interview with Employee 1, RN, on January 7, 2024, at approximately 10:18 AM, confirmed the observation, and stated it was her drink, and winter coat. She further acknowledged she had not adhered to infection control procedures…
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 · E2024-01-10 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the minutes from resident group meetings and grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to demonstrate their response to resident complaints and grievances raised at group meetings, including complaints raised by four of the five residents (Residents 14, 40, 44, and 88) interviewed during a group interview. Findings include: During a resident group interview on January 8, 2024, at 10:00 AM, Residents 14, 40, 44, and 88 reported that they had raised concerns regarding the facility, which were affecting the quality of their care and/or quality of their life in the facility, during resident group meetings and individually over the past few months. The four residents stated that, to date, the facility did not address or attempt to address their complaints or grievances. During the resident group interview on January 8, 2024, at 10:00 AM, Resident 14 stated that he has complained many times to staff because of residents screaming and yelling near his bedroom. He explained that he is frustrated…
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 before2024-01-10 · 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 interviews with residents it was determined that the facility failed to maintain comfortable sound levels and reasonable protection of the resident's private space to maintain a homelike environment for residents including four of five interviewed during a group meeting (Residents 14, 40, 44, 88). Findings included: During the resident group interview on January 8, 2024, at 10:00 AM, Resident 14 stated that he has complained many times to facility staff that other residents screaming and yelling near his bedroom is noisy. He explained that he is frustrated because staff tell him that the other residents have a right to yell. Resident 14 reported that the facility has not addressed these disruptive behaviors displayed by other residents. During the resident group interview on January 8, 2024, at 10:00 AM, Resident 40 stated that that she has complained to facility staff about other residents screaming and yelling in the hallway near her room. She stated that she is upset by this disruptive behavior and noise but when she raised this issue with staff, staff told her 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.
- Potential for harm · Ecited before2024-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to consistently implement planned care and services consistent with professional standards of practice and the resident's plan of care to prevent the development and worsening of pressure ulcers for two residents out of the 24 sampled residents (Residents 49 and 29). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults (the ACP is the largest medical-specialty organization and second-largest physician group in the United…
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 · E2024-01-10 · 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 a review of clinical records, and staff interview, it was determined that the facility failed to implement individualized approaches to prevent declines in bowel continency and restore normal bowel function to the extent possible for two residents (Resident 18 and 56) and failed to assess a resident's bladder function following removal of indwelling foley catheter for one resident (Resident 165) out of five sampled. Findings include: A review of Resident 18's clinical record revealed admission to the facility on October 20, 2022, with diagnoses of osteoarthritis, transient cerebral ischemic attack (mini stroke - TIA), protein-calorie malnutrition, and hypertension. A review of Resident 18's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 5, 2023, section H, bowel and bladder, revealed that the resident was always continent of bowel. A review of Resident 18's quarterly MDS assessment dated [DATE],…
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 · E2024-01-10 · tag F0744 — failed to care for residents with dementia — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that a resident's individualized dementia care needs are consistently met and that the facility assessed, developed, and implemented interdisciplinary care planned approaches and provided resources necessary for management of dementia related behaviors for one residents out of eight sampled residents (Resident 65). Findings include: A review of the clinical record revealed Resident 65 was admitted to the facility on [DATE], with diagnoses that included altered mental status, anxiety, and dementia without behavioral disturbance. A review of a BIMS (brief interview for mental status - a tool to assess cognitive status) report dated November 2, 2023, indicated that the resident was severely cognitively impaired with a BIMS score of 0. Resident 65's care plan, dated October 30, 2023, noted a goal that the resident adjust to the facility and participate in activity programs 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 · E2024-01-10 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 medications on one of two medication carts observed (Station B, Back Hall, B Hall - Resident 4, 8, 31, 55, and 86) and failed to secure one of two medication rooms to prevent unauthorized access (A Unit Medication Room) Findings include: A review of facility policy entitled Insulin Administration last reviewed by the facility January 2, 2024, indicated that the steps in the procedure includes to check the expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial. Observation of medication administration pass conducted on January 7, 2024, at approximately 10:45 AM, with Employee 2, Licensed Practical Nurse (LPN), on the Station B, Back Hall, B Hall medication cart revealed one (1) Insulin Levemir Flex Pen belonging to Resident 4, opened and available for use, and not dated when initially opened, and or an expiration date; one (1)…
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 · D2024-01-10 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 the RAI manual and staff interview, it was determined that the facility failed to timely complete a significant change Minimum Data Set assessment for one of the 24 residents reviewed (Resident 98). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicates that a significant change MDS assessment must be completed no later than the assessment reference date (ARD) plus 14 calendar days. A clinical record review revealed a significant change MDS assessment for Resident 98 with an ARD dated October 8, 2023. However, the MDS assessment was not signed as completed until November 1, 2023, which was 10 days late. During an interview on January 9, 2024, at approximately 1:00 PM, the facility's Registered Nurse Assessment Coordinator (RNAC) confirmed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-10 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the Resident Assessment Instrument Manual and clinical records, and staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within the required time frame for one of three closed records reviewed (Resident 111). Findings included: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS) dated [DATE], requires that MDS Discharge Assessment-Return Not Anticipated (Non-Comprehensive) be completed no longer than the resident's discharge date + 14 calendar days. A clinical record review revealed that Resident 111 left the facility against medical advice to live in the community on November 10, 2023.…
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 before2024-01-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 24 sampled (Residents 29). Findings include: A review of Resident 29's Quarterly MDS assessment dated [DATE], Section P0100 Physical Restraints, indicated the resident had a restraint. Review of Resident 29's clinical record and observations performed during survey failed to provide evidence that the resident had a restraint in place. Interview with the Director of Nursing on January 8, 2024, at approximately 1:44 PM confirmed the resident's quarterly MDS assessment was inaccurate.
- Potential for harm · D2024-01-10 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, observations, and staff interview it was determined that the facility failed to ensure that the facility provided enteral feedings as prescribed and services designed to prevent potential complications associated with tube feedings for one resident out of two residents sampled receiving enteral tube feedings (Resident 67). Findings include: A review of facility policy entitled Enteral Tube Feeding via Continuous Pump last reviewed by the facility January 2, 2024, revealed procedures that when initiating the feeding, on the formula label staff are to document initials, date and time the formula was hung/administered prior to starting pump. Review of Resident 67's clinical record revealed that she was most recently admitted to the facility on [DATE], with diagnoses, which included Downs syndrome, sacral pressure ulcer (bed sore), protein-calorie malnutrition, and hypertension. According to the clinical record, Resident 67 required a percutaneous…
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 · D2024-01-10 · 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 a review of the clinical record and resident and staff interviews, it was determined that the facility failed to provide person-centered and coordinated care for one out of the one sampled resident receiving dialysis (Resident 14). Findings include: A clinical record review revealed Resident 14 was admitted to the facility on [DATE], with a diagnosis of end-stage renal disease (final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) and with a dependence on renal dialysis (a process of purifying the blood of a person whose kidneys are not working normally), and an acquired absence of kidney. A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 19, 2023, revealed that Resident 14 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the…
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 · D2024-01-10 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of clinical records and the facility's planned cycle menus, observation and staff interviews it was determined that the failed to assure that a resident received foods with the appropriate nutritive content as prescribed by the physician to support the resident's treatment of kidney disease for one resident out of one sampled receiving dialysis (Resident 14). Findings include: A review of the clinical record of Resident 14 revealed admission to the facility on October 25, 2022, with a diagnosis of end-stage renal disease (final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) and absence of a kidney. The resident was dependent on renal dialysis (a process of purifying the blood of a person whose kidneys are not working normally). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 19, 2023, revealed that Resident 14 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool…
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 before2023-11-14 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 nursing staffing hours and ratios, observations and resident, family and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents in the facility including Residents 1, 2, and 3. Findings include: Observations on November 14, 2023, at 11:45 AM on the A nursing unit revealed one nurse manager working the desk at the nurse's station, two nurses working the medication carts and 3 nurse aides on duty. Observations on the B nursing unit on November 14, 2023, revealed one nurse manager working the desk at the nurse's station, two nurses working the medication carts, and 4 nurse aides on duty. Observations of the A nursing unit on November 14, 2023, at 11:50 AM revealed Resident 1's call bell was ringing in resident room [ROOM NUMBER]. Resident 2's call bell was also ringing in resident room [ROOM NUMBER]. 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 · D2023-02-24 · 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 a review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician and notify resident's representative, of a significant weight loss, for one resident out of two sampled residents (Resident 26). Findings include: Review of facility policy change in resident's condition or status revealed that the facility will notify the physician and responsible party within 24 hours of a resident's change in status. A review of the clinical record revealed that Resident 26 was admitted to the facility on [DATE], with diagnoses to include moderate protein calorie malnutrition. A quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated February 2, 2023, indicated that the resident is cognitively intact. The resident's clinical record revealed a primary representative (responsible party and emergency contact #1) as a family member (daughter). The resident's weight…
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 before2023-02-24 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 20 sampled (Resident 22, 43, and 96). Findings include: A review of Resident 22's clinical record revealed that the resident had diagnoses, which included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and required dialysis three times weekly on Mondays, Wednesdays, and Fridays. A review of Resident 22's clinical record, quarterly MDS assessment dated [DATE], revealed that Section O0100 Special Treatment Procedures and Programs indicated the resident did not receive dialysis in the last 14 days.…
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 · D2023-02-24 · 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 interview, it was determined that the facility failed to accurately and consistently assess residents' nutritional status and parameters and timely implement measures to prevent weight loss for one of 19 residents sampled (Resident 67) Findings include: Review of the facility policy entitled Weight Assessment and Intervention last revised March 2022, indicated that it is the facility policy that weights will be obtained upon admission and at intervals established by the interdisciplinary team. However, at the time of the survey ending February 24, 2023, the facility was following a November 2020 policy for obtaining weights during the COVID 19 pandemic whereas resident weights will be deferred during resident isolation due to COVID 19. A review of the clinical record revealed that Resident 67 was admitted to the facility on [DATE], with diagnoses to include Downs Syndrome. A review of Resident 67's weight record revealed an admission…
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 before2023-02-24 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of clinical records and nurse staffing, and staff and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely and quality of care and assistance to residents' request for care via the facility nurse call bell system to maintain the physical and psychosocial well-being of two residents out of 20 sampled (Residents 27 and 35). Findings include: Review of Resident 27's clinical record revealed the resident had diagnoses, which included Parkinson's disease. A quarterly Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated February 1, 2023 indicated the resident was cognitively intact with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 13 (a score of 13-15 indicates cognitively intact) and required the assistance of two staff for toileting. Observations on February 21, 2023, at 1:20 PM and 1:30 PM revealed Resident 27's call light was on (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.
- No harm found · Bcited before2023-02-24 · 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 — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined that the facility failed to provide maintenance services to maintain a clean and homelike resident environment. Findings include: An observation on February 23, 2023, at 1:10 PM revealed the exterior door frames of Resident rooms 100, 104, 219, 221, 223, and 226 had large areas of chipped paint. During an interview February 23, 2023, at approximately 2:00 PM the administrator (NHA) confirmed that the chipped paint occurred when maintenance staff removes zippered plastic (which is placed on the resident room for the isolation period when a resident tests positive for COVID-19) after the resident is no longer in isolation. The NHA confirmed the observations and the facility's failure to maintain a clean and homelike environment. 28 Pa Code 207.2 (a) Administrators responsibility
“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
$19,760 in federal fines across 1 penalty.
- $19,760 — penalty dated 2023-11-14
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CONTINUUM HEALTHCARE — 13 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 | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 12 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|
| HIGHLAND MANOR REAL PROPERTY, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE HOLDINGS LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 10/03/2019 |
| LITMAN, WARREN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2024 |
| CONTINUUM HEALTHCARE I INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
| EXECUCARE ASSOCIATES | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/15/2025 |
| LESHKOWITZ & COMPANY LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| TWOMAGNETS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
| DORN, CHERYL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2022 |
| MANDELBAUM, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2019 |
| MARTIN, TRAVIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/29/2024 |
| MUSTO, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE MEMBER I LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE MEMBER II LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE MEMBER III LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| BRUCKSTEIN, DANIEL | Individual | ADP OF THE SNF | since 10/03/2019 |
| BRUCKSTEIN, ROBERT | Individual | ADP OF THE SNF | since 10/03/2019 |
CMS files one row per role, so the 25 rows in the source record cover these 16 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.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% 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 $689K 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 395566. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-19, 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.