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Transitions Healthcare Gettysburg

595 Biglerville Road, Gettysburg, PA 17325 · For profit - Limited Liability company · 135 certified beds · (717) 334-6249 Medicare & Medicaid certified

Call the home — (717) 334-6249 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20242 actual-harm citations$16,334 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,334 in federal fines (most recent 2024-06-11)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
147 N Washington St · (717) 337-2684 · Call to confirm hours
Pharmacy
46 Chambersburg St · (866) 430-9222 · Call to confirm hours
Grocery
735 Old Harrisburg Rd · (717) 337-1753 · Call to confirm hours
Park
Doubleday Ave · Typically dawn to dusk
Place of worship
300 N Washington St · (717) 337-6280

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased31.5%16.8%15.4%worse
Long-stay residents who lose too much weight4.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.7%0.9%better
Long-stay residents with a urinary tract infection1.9%1.5%2.0%typical
Long-stay residents with depressive symptoms0.0%10.8%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.3%3.1%3.3%typical
Long-stay residents whose ability to walk worsened22.5%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.4%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine90.6%93.5%95.3%typical
Long-stay residents with pressure ulcers3.2%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control18.9%25.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.0%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.6%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine51.8%68.7%79.4%worse
Short-stay residents rehospitalized after admission18.5%22.5%22.6%better
Short-stay residents with an outpatient ER visit18.2%9.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.641.621.67typical
Long-stay outpatient ER visits per 1,000 resident days1.531.181.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. 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.

55.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 204 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.7%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
55.0%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 55.0% 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 80 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.7%CMS range 48.2–62.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 7.1–12.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified91.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.7%CMS range 3.6–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.51
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.74
Total nurse hours/ resident / day
0.32
RN hoursweekends
49.6%
Total nursing turnover
53.3%
RN turnover

How full it usually is: this home is certified for 135 beds and averages 126.9 residents a day — about 94% occupied, or roughly 8 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below 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 3.40 hrs/resident/day on weekends vs 3.88 on weekdays — 12% thinner on weekends. RN hours go from 0.58 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 50% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

6
deficiencies at the latest standard inspection (2025-11-18)
6
at the previous standard inspection (2024-08-15)

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.

ABCDEFGHIJKL

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

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2024-06-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, facility documentation review, facility policy review, hospital records review, and staff and resident interviews, it was determined that the facility failed to ensure that residents were protected from neglect during provision of care for one of four residents reviewed (Resident 1). The facility staff member failed to verify the resident and transfer status, which resulted in actual harm to Resident 1 who sustained a laceration to the right lower leg, transfer to the hospital, and received 13 sutures to the right lower leg. Findings Include: Review of the facility's policy, titled Abuse Prohibition-Abuse, Neglect, and Misappropriation of Resident's Property, revised June 14, 2023, revealed that neglect is defined at 483,5 as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy review, review of facility investigation reports, hospital record review, and resident and staff interviews, it was determined that the facility failed to provide the assistance required for a safe transfer for one of four residents reviewed (Resident 1), resulting in actual harm as evidenced by a laceration that required transfer to the hospital and 13 sutures. Findings Include: A review of the facility policy, titled Transfer/Lift Policy, stated, all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's care plan. Review of Resident 1's clinical record revealed that the Resident was admitted to the facility on [DATE], with diagnoses that included anorexia nervosa (an eating disorder causing people to obsess about weight and what they eat) and failure to thrive (doesn't gain weight normally). A review of Resident 1's Quarterly Minimum Data Set (MDS-a periodic review of a resident's assessment and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-18 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident's right to file a grievance anonymously was honored on three of three resident living areas.Findings include: Review of facility, titled OPS-352 Grievance Policy, with a last review date of August 27, 2025, revealed, in part, 1. A concern/grievance may be made in person, in writing, by telephone or by mail and may be reported anonymously. The facility may not require the signature of the resident, the resident's representative or concerned party on a concern/grievance. 2. Grievance forms are located at each nursing station, the receptionists' office and outside the Social Service office. Forms may be returned to the receptionists' office, the Social Service department and/or to facility staff and management. During a Resident group meeting with Residents 30, 51, 55, 66, and 76 on September 23, 2025, at 10:30 AM, Residents 30, 51, 66, and 76, all indicated that they did not know how to file a grievance or how to do it anonymously. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of two residents reviewed (Resident 5).Findings include: Review of facility policy, titled CLIN-157 CPAP/BIPAP, with a last review date of August 27, 2025, revealed, in part, orders must include pressure and hours of use and may include supplemental oxygen and mask size. The policy failed to indicate how the mask was to be stored when not in use. Review of Resident 5's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, and legal blindness. Review of Resident 5's current physician orders revealed an order for CPAP (continuous positive airway…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-18 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for four of 24 residents reviewed (Residents 5, 75, 99, and 118).Findings include:Review of the facility policy, titled OPS Minimum Data Set Submission/Accuracy, with a last review date of August 27, 2025, stated, Each Minimum Data Set Submission (MDS) [an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs] will be completed accurately and timely and in accordance with RAI (Resident Assessment Instrument) guidelines and requirements.Review of Resident 5's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observation, 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 two of 24 residents reviewed (Residents 5 and 116).Findings include: Facility policy, titled Care Plan - Comprehensive, last reviewed August 27, 2025, read, in part, Each resident will have a comprehensive care plan developed that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. Care plan interventions are designed after careful consideration of the relationship between the resident's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 one of 24 residents reviewed (Resident 5).Findings include: Review of facility policy, titled Care Plan - Comprehensive, last reviewed August 27, 2025, read, in part, Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition changes. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; d. At least quarterly. Review of Resident 5's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, muscle weakness, and moderate protein-calorie malnutrition (the state of inadequate food intake which leads to changes…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-18 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, food committee meeting minutes, grievance review, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were at an appetizing temperature.Findings include:Review of Food Committee Meeting Minutes from July 29, 2025, revealed under complaints/concerns veggies are cold.Review of May 2025 Grievance Log revealed Resident 34 filed a grievance on May 6, 2025, that she feels she should be able to have her tea served hotter. Residents 30, 51, 66, and 76 who attended a group meeting on September 23, 2025, at 10:40 AM, revealed food temperatures are sometimes cold and they have to ask staff to reheat their food, and that coffee is often not hot enough. During an interview with Resident 4 on September 23, 2025, at 10:40 AM, he revealed his food isn't always served hot. Observation during meal tray line service on September 23, 2025, at 11:51 AM, revealed staff were placing two mugs with handles on the trays. Interview with Employee 1 (Dietary Manager) on September 23, 2025, at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of five residents reviewed (Resident 108). Findings Include: Review of facility policy, titled Pressure Ulcer Prevention and Management, revised September 13, 2019, revealed in a section Pressure relief: Elevate/float heels or obtain a device to provide pressure relief. Review of Resident 108's clinical record revealed diagnoses of muscle weakness (weakness in the muscles that makes movement difficult) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin). Review of Resident 108's current physician order on August 12, 2024, at 2:35 PM, revealed a physician's order for Blue off-loading boots to B/L (bilateral) heels, with an order date of July 22, 2024. Observation of Resident 108 on August 12, 2024, at 1:48 PM, revealed the Resident was not wearing blue off-loading boots to elevate her heels off 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-15 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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, product label review, facility policy review, and staff interview, it was determined that the facility failed to store drugs used in the facility in accordance with currently accepted professional principles and the expiration dates for two of three medication carts observed (Annex 1 North medication cart and Annex 1 South medication cart). Findings Include: Review of facility provided policy, Storage of Medications, effective September 2018, revealed, Medication and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Observation of the Annex 1 North medication cart on August 15, 2024, at 9:40 AM, revealed one Ozembic (a prescription injectable medication used to treat type 2 diabetes) that was currently in use and was not labeled with a date that it was opened. The observation at that time also revealed a Levemir pen (a prescription injectable medication used to treat type 2 diabetes) that was unopened, not refrigerated, and was not labeled with the date it had been removed from…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0810 — pattern
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 24 residents reviewed (Resident 59). Findings include: Review of facility provided policy, titled Restorative Adaptive Equipment, with a revision date of March 28, 2016, revealed, Restorative adaptive equipment and assistive devices will be used to promote individual resident functional level and to prevent decline. Review of Resident 59's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and hemiplegia (one-sided weakness caused by brain or spinal cord problems). Review of Resident 59's care plan revealed a focus area of, [Resident 59] is on a therapeutic, mechanically altered diet, with a date initiated of May 29, 2019, and a revision date of January 5, 2022. Further review of this care plan revealed an intervention of, Dycem on side table with meals in dining room, with a revision date of April 23, 2024. Review of Resident 59's current physician's orders on August 12, 2024,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, clinical record review, and policy review, it was determined that the facility failed to follow the facility policy for reporting an allegation of neglect to the Nursing Home Administrator (NHA) immediately for one of 24 residents reviewed (Resident 5). Findings include: A review of the facility policy, titled Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, last revised June 14, 2024, stated, any report or suspicion of an incident is to be reported immediately to the charge nurse/supervisor. The Administrator or the Director of Nursing who receives the report are to be notified immediately by the charge nurse/supervisor who receives the report. A review of the clinical record for Resident 5 on August 13, 2024, revealed diagnoses that included obstructive and reflux uropathy (obstructive or functional impediment of urine flow and back-up of urine flow) and bullous pemphigus (a rare autoimmune skin disease that causes blisters to form between the skin's epidermal and dermal layers of the skin). A review of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-08-15 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 27 residents reviewed (Residents 14, 20, and 51). Findings Include: Review of Resident 14's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream) and history of traumatic brain injury (injury to the brain caused by an external force). Review of Resident 14's physician orders revealed an order for Insulin Glargine, inject 6 units at bedtime for type 2 diabetes, hold for blood sugar level less than 150, starting May 10, 2024. Further review indicated an administration time of 9:30 PM. Review of Resident 14's physician orders also revealed an order to check blood sugar levels before meals and at bedtime, starting May 10, 2024. Further review revealed scheduled times for blood sugar monitoring were 6:30…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 observations, clinical record review, policy review, and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed for respiratory care (Resident 9). Findings include: Review of facility policy, titled Clin - 157 CPAP/BIPAP, last reviewed March 2024, revealed that when cleaning the system: clean the unit weekly. Review of Resident 9's clinical record revealed diagnoses that included stage 3 chronic kidney disease (when your kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood) and pulmonary fibrosis (a lung disease that occurs when lung tissue become damaged and scarred). During an observation of Resident 9 on August 12, 2024, at 1:57 PM, revealed a CPAP (continuous positive airway pressure) machine and mask sitting on Resident 9's night stand beside their bed, not dated. Review of Resident 9's clinical record revealed a physician's order for CPAP on at bedtime, remove in the AM every shift, and encourage use during naps,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-26 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 27 residents reviewed (Residents 3, 34, 61, and 117). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included nicotine dependence and diabetes mellitus Type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 3's physician orders revealed no orders for insulin; however, there was an order for Trulicity (injectable medication used to treat type II diabetes, but is not insulin) Subcutaneous Solution Pen-injector 0.75 milligrams/0.5 milliliters (dulaglutide) Inject 0.75 mg subcutaneously one time a day every Friday related to type II diabetes mellitus, dated September 11, 2023. Review of Resident 3's order history revealed that they had been on Trulicity since August 6, 2021. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-26 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff and resident interviews, it was determined that the facility failed to develop and/or implement a comprehensive person-centered care plan for three of 24 residents reviewed (Residents 28, 36, and 106). Findings include: A review of the clinical record for Resident 28 revealed diagnoses that included nicotine dependence (when you need nicotine [tobacco] and can't stop using it) and chronic obstructive pulmonary disease (COPD - disease process that causes decreased ability of the lungs to perform). During an interview with Resident 28 on October 25, 2023, at 10:35 AM, Resident 28 stated that she smoked cigarettes prior to being admitted to the facility, and the facility is providing interventions for her to quit smoking because the facility is a non-smoking facility. Further review of Resident 28's care plan failed to reveal any care plan regarding her diagnosis of nicotine dependence or interventions to assist her in remaining free from the desire for tobacco use. During an interview with the Nursing Home Administrator and the Director of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review, review of facility provided documents, and staff interviews, it was determined that the facility failed to ensure that the resident environment was free of accident hazards for two of 27 Residents reviewed (Residents 47 and 61). Findings include: Review of Resident 47's clinical record revealed diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and hypertension (high blood pressure). Observation of Resident 47 on October 23, 2023, at 10:04 AM, revealed the Resident lying in bed. Resident 47's bed had bilateral enablers. Observation of Resident 47 on October 25, 2023, at 10:46 AM, revealed the Resident lying in bed. Resident 47's bed had bilateral enablers. Review of Resident 47's care plan revealed a care plan with a focus area of: Resident 47 has an ADL (Activities of Daily Living) self-care performance deficit related to dementia, with an intervention of left side assistive rail to enable Resident to turn and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-26 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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, and policy review, it was determined that the facility failed to ensure appropriate labeling (opened date) of medication for three of six medication carts (Annex 1 cart, South Wing cart, and East Wing cart) that effected eight residents (Residents 7, 34, 35, 36, 37, 73, 80, and 95); failed to have refrigerated one unopened vial that effected one resident (Resident 80); and failed to have an open date or resident name on one medication that was stored with medications in use. Findings include: Review of facility, policy titled Administration Procedures for All Medications, with a revision date of August 2020, revealed in Section IV, Number 1, When opening a multidose container, place the date on the container. Observation on October 25, 2023, at 12:25 PM, revealed the following in the South Wing medication cart: Humalog (insulin) Kwikpen Injection 100 Units/ml (insulin) for Resident 37, opened and not dated. Insulin Degludec Pen 200 Units/ml for Resident 35, opened and not dated. Insulin Degludec vial 100 Units/ml for Resident 73 opened 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in three of three nourishment rooms. Findings include: Observations on October 23, 2023, at 10:50 AM, of the Annex 1 nourishment room revealed the following: the base of the freezer was noted to have a sticky brown colored substance; the refrigerator contained two Ready Care vanilla shakes dated with a use by date of October 20, 2023; the ice chest cooler was noted with a black residue around the rim of the lid; the ice scoop was stored in a separate bin on the side of the cooler, but was uncovered, and the cart for the cooler was noted to have a brown colored residue; the microwave was noted with a heavy build-up of a black substance, the plastic coating of the microwave looks as if it was melted, and there was orange-red food splatter on the sides. Observations on October 23, 2023, at 1:59 PM, of the Rehabilitation Unit revealed the following: freezer was noted to have loose food debris particles; 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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, clinical record 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. Findings include: Review of facility policy, titled Multidrug Resistant Organisms (MDRO), with a last revision date of October 1, 2017, revealed in subsection Contact Precautions: 3) Should a resident be placed on Contact Precautions, implement the facility's Contact Precautions policy. Review of facility policy, titled Transmission Based Precautions, with a last revision date of September 28, 2022, revealed in subsection: Contact Precautions, Place isolation sign at door of resident's room. Review of Resident 3's clinical record revealed diagnoses that included Enterococcus (a type of bacteria that develops resistance to many antibiotics, especially vancomycin, that is spread from person-to-person or from contaminated…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-26 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel file review and staff interview, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year, and/or that this training included dementia management and resident abuse prevention, for seven of seven nurse aide employee records reviewed (Employees 3, 4, 5, 6, 7, 8, and 9). Findings Include: Review of select facility documentation revealed that Employee 3 was hired on November 18, 2019; Employee 4 was hired on October 4, 2011; Employee 5 was hired on August 9, 2011; Employee 6 was hired on July 19, 2019; and Employee 7 was hired on November 29, 2021. Review of training records provided by the facility failed to reveal evidence that Employees 3, 4, 5, 6, and 7 received at least 12 hours of annual in-service training. Further review of training records failed to reveal evidence that Employee 3 received in-service training that included dementia management and resident abuse prevention. Further review of training records failed to reveal evidence that Employees 8 and 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for three of 27 residents reviewed (Residents 36, 41, and 70) Findings include: Review of facility policy, titled IDT (Interdisciplinary Team) Care Planning, with a last revision date of September 19, 2019, indicated, The care plan is revised when appropriate to reflect the resident's current needs based on the team's evaluation of the plan: 1) the resident's progression; 2) the resident's response to care and treatment; and 3) any significant changes in the resident's status. Review of Resident 36's clinical record revealed diagnoses that included localized edema (swelling caused by excess fluid accumulation in the body tissues) and venous insufficiency (condition in which blood pools in the veins, straining the walls of the vein causing swelling, pain, and skin changes).…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, observations, and staff and resident 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 each resident's physical, mental, and psychosocial needs for three of 27 residents reviewed (Residents 36, 95, and 117). Findings include: Review of Resident 36's clinical record revealed diagnoses that included localized edema (swelling caused by excess fluid accumulation in the body tissues) and venous insufficiency (condition in which blood pools in the veins, straining the walls of the vein causing swelling, pain, and skin changes). Review of Resident 36's physician orders revealed an order to apply ace wraps daily, on in the morning and off at bedtime, effective October 17, 2023. Observation on October 23, 2023, at 1:30 PM, revealed Resident 36 was not wearing ace wraps to his legs. The wraps were observed on top of his dresser, rolled neatly. During an interview with the Director of Nursing (DON) on October 26, 2023, at 10:05 AM, she revealed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of one residents reviewed (Resident 7). Findings include: Review of Resident 7's clinical record revealed diagnoses that included muscle weakness and hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels of the brain) affecting right dominant side. Review of Resident 7's physician orders revealed an order for a right elbow brace (on in AM after care) for up to four hours or as tolerated for contracture (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) prevention, dated September 5, 2023. Review of Resident 7's care plan revealed a care plan focus for potential for pain related to history 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to complete a timely assessment for trauma, and then develop and implement an individualized person-centered care plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one out of 24 residents reviewed (Resident 107). Findings include: Review of Facility Policy, titled Trauma Informed Care, effective November 28, 2019, revealed, The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident .Within 72 hours of admission, Social Services will perform an initial trauma evaluation of residents using the Trauma Questionnaire .Any resident who scores a 3 or higher is deemed positive for a traumatic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$16,334 in federal fines across 2 penalties.

  • $8,167 — penalty dated 2024-06-11
  • $8,167 — penalty dated 2024-06-11

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 TRANSITIONS HEALTHCARE — 6 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 →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 3 of 53.2-0.2 vs chain
The other 5 homes this chain runs (chain average 2.7★, 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 / managerTypeRoleShareSince
FELDMAN, MARCIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF33%since 08/09/2011
MAURANO, MATTHEWIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF33%since 08/09/2011
WILLIAMS, KEVINIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF33%since 08/09/2011
AVIV FINANCING II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/09/2011
AVIV HEALTHCARE PROPERTIES OPERATING PARTNERSHIP I LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/09/2011
AVIV OP LIMITED PARTNER LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2016
OHI HEALTHCARE PROPERTIES HOLDCO, INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2016
OHI HEALTHCARE PROPERTIES LIMITED PARTNERSHIPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2016
CORLEY, LISAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/16/2025
DECORT, RYANIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
TRANSITIONS HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/09/2011
BIGLERVILLE ROAD LLCOrganizationADP OF THE SNFsince 08/09/2011

CMS files one row per role, so the 24 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$14.7M
Net patient revenuemost recent cost report
-8.5%
Operating marginrevenue minus expenses
$746K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 8%Other / private 92%

This home reported $746K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$352per resident / day
operating cost
$10,705per month
≈ monthly operating cost
$324per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395798. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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