Paramount Nursing And Rehab At Fayetteville, LLC
6375 Chambersburg Road, Fayetteville, PA 17222 · For profit - Corporation · 92 certified beds · (717) 352-2721 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0606), cited Aug 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,345 in federal fines (most recent 2025-10-06)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.4% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.7% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.7% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.4% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.6% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 26.7% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 29.1% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 29.9% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.7% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 89.4% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.7% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.6% | 9.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.37 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.86 | 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.
33.8% 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 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 7.6% 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 92 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 0.38 therapist hours per resident per day in 2026Q1 — more than 66% 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 | 33.8%CMS range 27.4–41.7 | 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 | 9.2%CMS range 6.0–13.3 | 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 | 7.6% | 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 | 9.8% | 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 | 12.0% | 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 | 97.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 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 | 3.8% | 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 | 7.8%CMS range 5.1–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 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 92 beds and averages 85.0 residents a day — about 92% 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.14 hrs/resident/day on weekends vs 3.56 on weekdays — 12% thinner on weekends. RN hours go from 0.48 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% 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 unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2025-10-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, select facility document review, policy review, review of diet guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in accordance with professional standards of practice to meet the needs of each resident for one of nine residents reviewed (Resident 1). This failure resulted in an Immediate Jeopardy situation for Resident 1 as evidenced by a delay in provision of emergency services which resulted in death.Findings include:Review of facility policy, titled Emergency Procedure-Choking, with a last review date of January 23, 2025, revealed the following, in part, Trained staff will assist the resident which is choking by attempting to expel the foreign body from the airway. Conscious Resident-Standing or Sitting:1. Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. 4. Call for help, but stay with the resident. 6. If 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.
- Immediate jeopardy · J2025-10-06 · 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
Based on clinical record review, select facility document review, review of diet guidelines, review of select resident meal tray tickets, and staff interviews, it was determined that the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents based on individual needs for one resident (Resident 1), which resulted in Resident 1 choking. This failure placed nine residents that had similar diet needs at a high risk for death and resulted in an Immediate Jeopardy situation (Resident 6, 7, 8, 9, 10, 11, 12, 13 and 14).Findings include:Review of facility document, titled Mechanically Altered Diets, last reviewed January 23, 2025, read, in part, Dysphagia Diet Level 2: Level 2 can tolerate (most of the time) this texture as it should be the easiest to maneuver and safe to swallow. Mechanically altered food should be very small in size, soft, and with extra moisture added.Review of Resident 1's clinical record revealed diagnoses that included unspecified protein-calorie malnutrition (an imbalance between the nutrients the body needs to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-05 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a residents medication regimen was free from unnecessary psychotropic medications and failed to ensure that residents received adequate monitoring of psychotropic medications for three of five residents reviewed for unnecessary medications (Residents 41, 66, and 67). Findings include: Review of facility policy, titled Psychoactive Drug Monitoring Policy, undated, with a last review date of January 23, 2025, revealed It is the policy of the Skilled Unit of Paramount Nursing and Rehabilitation at Fayetteville, LLC. to monitor Residents who receive antidepressant, hypnotic, antianxiety, or antipsychotic medications. The purpose was identified as to evaluate the effectiveness of the medication and to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. In addition, 1) Residents receive a psychoactive medication only if…
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 before2025-06-05 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 ensure that resident assessments accurately reflected the resident's status for three of 25 residents reviewed (Residents 37, 41, and 67). Findings include: Review of Resident 37's clinical record revealed diagnoses that included cerebral infarction (death of brain tissue caused by a disruption in blood flow) and paraplegia (inability to move the lower part of the body). Review of Resident 37's quarterly minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) dated April 16, 2025, revealed Resident 37 was coded as receiving anticoagulant medication. Review of Resident 37's current and discontinued physician orders failed to reveal Resident 37 had been ordered anticoagulant medication. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on June 4, 2025, at 2:02 PM, it was revealed that Resident 37's quarterly MDS assessment had been coded incorrectly and a modification had been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-05 · 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 facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 18 residents reviewed (Residents 5, 41, and 66). Findings include: Review of the facility policy, titled Care Plan Policy, last reviewed January 23, 2025, read, in part, .to develop and maintain a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that include, but are not limited to, those identified in the comprehensive assessment . Using the initial plan of care, any updates, the comprehensive assessment and the resultant CAA investigations, the interdisciplinary team will meet with the resident and the resident's family or representative, as appropriate, and develop quantifiable objectives for the highest level of functioning the resident may be expected to attain - physically, mentally, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-05 · 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
Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure urinary catheter care was completed for three of four residents reviewed with urinary catheters (Residents 1, 21, and 41). Findings include: Review of the facility policy, titled Prevention of Catheter Associated Urinary Tract Infections, last reviewed January 23, 2025, under Catheter Care section stated, daily catheter care should be documented in the resident's EHR (electronic health record). Review of Resident 1's clinical record revealed diagnoses that included obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed) and type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy). Physician orders dated August 2024 through June 2025 identified that Resident 1 had an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Physician orders also stated catheter care was to be performed daily on every shift. Review of 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 · E2025-06-05 · tag F0699 — patternProvide 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
Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 18 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed diagnoses that included paraplegia (inability to voluntarily move the lower parts of the body) and depression (persistent feeling of sadness, loss of interest, or both, that interferes with daily life activities). During an interview with Resident 37 on June 2, 2025 at 12:09 PM, Resident 37 revealed that at the age of 19 he was the only survivor of a plane crash. Resident 37 also revealed he was severely injured in the crash, which resulted in him being paralyzed from the waste down. Further review of Resident 37's clinical record failed to reveal documentation that any trauma screening had been done. Email…
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 before2025-06-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food/beverages and utilize equipment in accordance with professional standards for food service safety in the kitchen and in one of one nourishment refrigerators. Findings include: Review of facility policy, titled Food Storage/Refrigerators, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 5. Foods must be stored in appropriate containers; covered, labels, and dated. 6. All food items must be stored 6 inches off the floor. Review of facility policy, titled Food Storage/Dry Storage, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 1. All foods or food items not requiring refrigeration shall be stored at least 6 inches off the floor and 18 inches from the ceiling. 2. Items must be stored on a surface, which facilitates thorough cleaning. 4. All items are stored and issued on a first in/first out rotation. All cans must be dated. 7. Any opened items must…
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 before2025-06-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 18 residents reviewed (Residents 41 and 67). Findings include: Review of facility policy, titled Care Plan Policy with a last revised date of February 20, 2020, and a last review date of January 23, 2025, revealed The Care Plan will be updated on an ongoing basis by the charge nurse whenever new nursing orders are received and/or any changes in condition with the resident. Review of Resident 41's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body). Review of Resident 41's physician orders revealed an order for fluid restriction of 2000 ml (milliliters) in 24 hours. Review of Resident 41's care plan revealed in 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 · Dcited before2025-03-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — the official record, unedited, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included atrial fibrillation (upper chambers [atria] of the heart beat rapidly and irregularly) and congestive heart failure (condition where the heart muscle is weakened and cannot pump blood effectively). Review of Resident 1's comprehensive plan of care revealed focus areas for ADLs (activities of daily living) and falls. Further review of Resident 1's care plan failed to include an intervention that indicated Resident 1's level of assistance required for ADL care. During an in interview on March 10, 2025 at 2:15 PM, with the Director of Nursing it was revealed that assistance type and level should be indicated on the Resident's care plan. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services
- Potential for harm · Dcited before2024-07-03 · 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
Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for two of 20 residents observed (Residents 35 and 54). Findings include: Observations of Resident 35's room on July 1, 2024, at 9:59 AM, and July 2, 2024, at 11:51 AM, revealed a pedestal fan with gray fuzzy debris on the blades and blowing from the front of the fan. Observations of Resident 54's room on July 1, 2024, at 11:18 AM, and July 2, 2024, at 11:52 AM, revealed a small fan sitting on a nightstand with gray fuzzy debris on the blades and blowing from the front of the fan. In an email communication received from the Nursing Home Administrator (NHA) on July 3, 2024, at 9:08 AM, the NHA revealed that the facility did not have a policy on the cleaning of fans. She further indicated that she had spoken to the housekeeping manager and that the cleaning of fans had now been added to the monthly resident room deep clean list. She also indicated that the housekeeping staff had cleaned all facility fans. In an interview with the NHA on July 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 · D2024-07-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent worsening of pressure ulcers for one of two residents reviewed for pressure ulcers (Resident 56). Findings include: Review of Resident 56's clinical record revealed diagnoses that included stage 4 pressure ulcer of the right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure), type 2 diabetes mellitus with foot ulcer (a metabolic disorder in which the body has high sugar levels for prolonged periods of time leading to breakdown of skin and sometimes deeper tissues), and hypertension (high blood pressure). Review of Resident 56's physician orders revealed an order for Heels up when in bed, with a start date of March 29, 2024. Further review of Resident 56's physician orders revealed an order for Offloading boot to be worn in bed to RLE (right lower extremity), with a start date of April 2, 2024. Review of Resident 56's weekly wound consultation notes revealed recommendations from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2024-07-03 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed (Resident 54). Findings include: Review of Resident 54's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and muscle weakness. Review of Resident 54's physician orders revealed an order for a palm protector to the right hand due to contracture (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints), may remove for care, dated May 21, 2024. Observation of Resident 54 and their room on July 1, 2024, at 11:18 AM, revealed Resident 54's palm protector was lying on a chair in their room and that Resident 54 was in an activity with no palm protector in place. Observation of Resident 54 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 · D2024-07-03 · 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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to monitor hydration status precisely and effectively for one of 20 residents reviewed (Resident 19). Findings include: Review of facility policy, titled Fluid Restriction Policy, last revised February 12, 2022, read, in part, Purpose: To ensure that fluid restricted residents receive adequate hydration by close monitoring .Care Plans will be updated to address interventions. Review of Resident 19's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF - long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), shortness of breath (uncomfortable feeling of not being able to breathe well enough), and acute upper respiratory infection. Review of Resident 19's physician orders revealed an order: Regular diet, Regular texture, Thin consistency (fluids), Fluid…
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 · D2024-07-03 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous (IV - tube inserted into a vein, which medication is administered through) therapy for two of two residents receiving IV medications (Residents 64 and 326). Findings Include: Facility policy, titled 13.6 Medication Administration Guidelines: Specific, effective date October 1, 2018, stated in part, 7. Compare the MAR (medication administration record) with the medication label for accuracy and note the following: A. Incorrect label or direction change by the health care provider .D. If the label and MAR differ for any other reason or if there are questions about the dosage or directions, do not administer the medication. Contact pharmacy provider. Review of Resident 64's clinical record revealed diagnoses that included osteomyelitis (infection of a bone) of the lumbar (lower back) region and discitis (an infection 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 · Dcited before2024-07-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain oxygen equipment in a sanitary manner and provide respiratory care consistent will professional standards for one of 20 residents reviewed for oxygen (Resident 19). Findings include: Review of facility policy, titled Oxygen Therapy Policy, last revised April 4, 2018, read, in part, Oxygen tubing will be dated and changed bi-weekly by the 11-7 Licensed Staff. Review of Resident 19's clinical record revealed diagnoses that included Covid-19 (respiratory virus), shortness of breath (uncomfortable feeling of not being able to breathe well enough), and muscle weakness. Observation of Resident 19's oxygen tubing on July 1, 2024, at 11:20 AM, revealed her oxygen tubing was dated June 2, 2024. Observation of Resident 19's oxygen tubing on July 2, 2024, at 10:07 AM, revealed her oxygen tubing was dated June 2, 2024. Review of Resident 19's clinical record revealed she tested positive for Covid-19 infection on June 20, 2024. During an…
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 · D2024-07-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of four residents reviewed (Residents 52 and 326). Findings include: Review of facility policy, titled Isolation Precaution Policy, with a last revised date of July 25, 2023, and a last reviewed date of January 25, 2024, revealed, in part, 1. This facility will follow CDC (Center for Disease Control) guidelines when determining what form of isolation precautions will be instituted i.e., Contact, Respiratory, or Enhanced Barrier Precautions; 2) Isolation precautions will be initiated by a physician's order and or deemed necessary by nursing judgment; and 5) A sign will be placed on the resident's door to alert staff and visitors. Review of facility policy, titled Shingles, with a last revised date of June 20, 2017, and a last reviewed 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 · Ecited before2023-08-10 · 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 observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 48 resident rooms (Resident 33, 36, 37, 39, 51, and 53 rooms). Findings include: Observation in Resident 36's room on August 7, 2023, at 11:19 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 36's room on August 8, 2023, at 10:49 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 53's room on August 7, 2023, at 11:25 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 53's room on August 8, 2023, at 9:46 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 39's room on August 7,…
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 before2023-08-10 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility for one of 21 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed diagnoses that included difficulty in walking, cerebral infarction (or stroke; when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and hypertension (high blood pressure). Interview with Resident 37 on August 7, 2023, at 11:44 AM, revealed he had a stroke with right sided weakness and needs assistance with turning and repositioning in bed. Resident 37 also revealed that he only gets turned and repositioned if he rings his call bell and asks to be turned and repositioned. Resident 37's Significant Change Minimum Data Set (MDS - assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an assessment reference date (last day…
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 before2023-08-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen and one of one nourishment areas. Findings include: Review of facility policy, titled 11.0 Food Service- Food Storage/Dry Storage last revised June 7, 2017, revealed Food items should be neatly arranged with labels facing forward, labeled with name, weight or count and date. Review of facility policy, titled 11.0 Food Service- Food Storage/Dry Storage last revised June 7, 2017, revealed Freezer temperature is 0 degrees Fahrenheit (unit of measure) or below at all times .Freezer temperatures are taken daily, each morning and recorded on the Record of Refrigerator and Freezer temperature log. Observation in the main dining area on August 7, 2023, at 9:40 AM, revealed: three containers of Raisin Bran cereal without a date; one container of Krave cereal without a date; one container of Apple…
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 · D2023-08-10 · tag F0606 — failed to not employ staff found guilty of abuse — isolatedNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, employee record review, and staff interviews, it was determined that the facility failed to ensure thorough background checks for new employees were conducted for three of five employee records reviewed (Employees 1, 2, and 3). Findings include: Review of facility policy, titled Criminal Background [C]hecks last revised June 20, 2017, revealed that in section titled Standard stated, To ensure that all applicants for employment and former employees reapplying for employment to [the] skilled nursing facilities have criminal background checks. It is the policy of Paramount Health Resources, Inc. to conduct criminal background checks in accordance with state and federal guidelines. Further review of the aforementioned policy revealed that in section titled Implementation subsection, 3. Facility Response stated, .If applicant has not resided in the state of Pennsylvania for the past 2 year's they are sent for fingerprinting for an FBI clearance. Review of Employee 1's employee record on August 9, 2023, at approximately 10:30 AM, revealed that Employee 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 · Dcited before2023-08-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 ensure that the resident assessment accurately reflected the resident's status for two of 21 resident records reviewed (Residents 26 and 37). Findings include: Review of Resident 26's clinical record revealed diagnoses that included Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Further review of Resident 26's clinical record revealed that they weighed 100 pounds on July 20, 2023; 108 pounds on June 13, 2023; 121 pounds on February 2, 2023; and 121 pounds on January 2, 2023. This indicated a weight loss of approximately 7% from June 2023 to July 2023, and an approximately 17% weight loss between January 2023 and July 2023. Review of Resident 26's July 23, 2023, comprehensive significant change MDS (Minimum Data Set - an assessment 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 · D2023-08-10 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 have the physician complete a discharge summary, which includes a recapitulation of the resident's stay, for one of two closed records reviewed (Resident 70). Findings include: A review of the closed clinical record revealed that Resident 70 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and sick sinus syndrome (irregular heart rhythm, alternating from slow to rapid heartbeats). Resident was post-hospitalization for placement of a pacemaker (surgically implanted electronic device to stimulate the heartbeat). Further review of Resident 70's clinical record revealed the Resident was discharged to home on May 15, 2023. Resident 70's closed clinical records failed to identify a discharge summary completed by the physician. The only documentation the facility was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and record review, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of 21 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record on August 8, 2023, revealed Resident 1 had diagnoses that included neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord, or nerve problem) and type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of the physician orders dated August 2023, confirmed that Resident 1 was ordered to have an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Observation of Resident 1 on August 7, 2023, at 11:15 AM, revealed Resident 1's catheter bag and tubing was dragging on the floor while mobile in her wheelchair in the hall. During an interview with the Director of Nursing (DON) on August 9,…
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 before2023-08-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for two of 19 residents reviewed (Residents 18 and 20). Findings include: A review of the facility policy, titled Oxygen Therapy last reviewed January 26, 2023, stated oxygen tubing/equipment should be dated when placed into use for the residents. Further review of the policy indicated that a physician's order for oxygen therapy should include the following information: administration modality, liter flow, whether it is continuous or prn (as needed), cleaning schedule, and instructions to change the tubing biweekly. The policy also revealed that the physician order should be reviewed as part of the procedure of administering oxygen therapy. A review of the clinical record for Resident 18 revealed clinical diagnoses that included hypertension (high/elevated blood pressure) and Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss 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 · D2023-08-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, clinical record review, and policy review, it was determined that the facility failed to ensure disposal of an unsecured/contaminated (cap missing) medication vial located in one of one medication refrigerator in the medication storage room; and failed adherence to medication expiration (use by dates) for one of two medication carts that affected one resident (Resident 46). Findings include: Review of facility policy, titled Medication Storage in the Facility last reviewed January 26, 2023, stated, Outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, and disposed of according to procedures for medication disposal. Observation on August 8, 2023, at 11:00 AM, revealed the following in the medication refrigerator located in the medication storage room: A box labeled Pneumococcal Vaccine 23 (vaccine indicated for active immunization for the prevention of pneumococcal pneumonia) with one vial remaining in a box that originally…
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
$17,345 in federal fines across 2 penalties.
- $8,672 — penalty dated 2025-10-06
- $8,673 — penalty dated 2025-10-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PARAMOUNT HEALTH HOLDINGS GROUP INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2017 |
| COX, JAMES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2018 |
| PARAMOUNT HEALTH RESOURCES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2018 |
| DARMSTADTER, CHASE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/21/2017 |
| RANDLER, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/27/2020 |
| DECORT, RYAN | Individual | ADP OF THE SNF | — | since 10/01/2024 |
CMS files one row per role, so the 13 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $516K 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 395721. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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.