Redstone Highlands Health Care

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

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.

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.

46.0% 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 198 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 28.4% 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 102 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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.

Staffing

How full it usually is: this home is certified for 77 beds and averages 73.1 residents a day — about 95% occupied, or roughly 4 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 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 is at or above 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 3.97 hrs/resident/day on weekends vs 4.84 on weekdays — 18% thinner on weekends. RN hours go from 1.81 to 1.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% 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

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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

45 citations, most serious first. The 17 most serious are shown; the remaining 28 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-10-15 · 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

  Based on review of policies, manufacturer's operations manual, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure adequate interventions and supervision to prevent elopements which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or harm for one of three residents identified at risk for elopement (Resident 3). The facility further relied on it's alarm system to prevent unsupervised exits, which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. This deficiency was cited as past non-compliance. Findings include:The facility policies for elopements and Wander Guards (a bracelet that triggers an alarm and can lock monitored doors to prevent the resident from leaving unattended), dated July 11, 2025, indicated that an Elopement Risk Observation would be completed by a licensed nurse upon admission, re-admission, and/or with any significant…

  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 · Past Non-Compliance
• Actual harm · Gcited before2026-03-12 · 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 review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Residents 3), resulting in a fracture. This deficiency is being cited as Past Non-Compliance. The facility's policy for Abuse Prohibition dated July 11, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility's policy for Using the Kardex in PCC: a quick guide, dated July 11, 2025, indicated that the Kardex (nursing documentation system used for quick, daily reference of patient care information, such as medications, allergies, activity levels, and treatment plans) is an essential…

  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 · Past Non-Compliance
• Actual harm · Gcited before2026-03-12 · 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for one of four residents reviewed (Resident 3) who required assistance with transferring from a bed to a chair. This deficiency is being cited as Past Non-Compliance. Findings include:The facility's policy for Using the Kardex in PCC: a quick guide, dated July 11, 2025, indicated that the Kardex (nursing documentation system used for quick, daily reference of patient care information, such as medications, allergies, activity levels, and treatment plans) is an essential tool within PCC (Point Click Care- type of electronic health record) for organizing, updating, and accessing crucial patient care information. Check at the start of your shift to make sure you have accurate information on transfer status, bed mobility, etc. An annual Minimum Data Set…

  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 · Past Non-Compliance
• Actual harm · Gcited before2025-08-05 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of four residents reviewed (Resident 2) resulting in a critically abnormal blood clotting time.Findings include:An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 2 dated April 20, 2025, indicated that the resident was moderately cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included heart failure. Review of clinical records revealed she was discharged from the facility on May 17, 2025. A medication error report for Resident 2 revealed that on May 11, 2025, a medication discrepancy was identified. The medication nurse realized that the pills in the resident's medication card labeled by the pharmacy as rosuvastatin calcium (a statin medication used to lower bad cholesterol and triglycerides) was actually Warfarin (coumadin-a blood thinner) tablets and not…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-08 · 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

  Based on review of policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for assisting with Activities of Daily Living (ADL's) and preventing falls for one of three residents reviewed (Resident 1), resulting in a fall and fracture for the resident. Findings include: The facility's policy regarding resident abuse, dated September 27, 2024, revealed that all management and staff are responsible to ensure that every resident will be free from verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, neglect, retaliation, humiliation or misappropriation of resident property. That neglect refers to a failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate and appropriate services, treatment and care, including but not limited to nutrition, medication, therapies and ADL's. A quarterly Minimum Data Set (MDS) assessment (a mandated…

  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 before2025-04-08 · 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 review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that staff implemented care-planned interventions for one of three residents reviewed (Resident 1) who was identified as a fall risk, resulting in a fall with fracture for the resident. Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2025, revealed that the resident was understood, could understand others, and had diagnoses which included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems). Current care plans for Resident 1 revealed that he had a self-care deficit related to decreased mobility, he required assist of two staff for bed mobility and transfers, was at risk for falls related to the need for assistance with his balance, and had a communication problem related to his cognition. Staff were to ensure/provide a safe environment.A nursing note for Resident 1, dated…

  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
• Actual harm · Gcited before2025-04-08 · 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

  Based on review of the investigation reports and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of three residents reviewed (Resident 1) resulting in a fall with fracture. Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems). The resident's care plan, dated September 17, 2020, revealed that the resident was at risk for falls related to the need for assistance with his balance. A care plan, dated October 10, 2023, revealed that the resident had a communication problem related to his cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and staff was to ensure/provide a safe environment. A care plan,…

  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 before2026-04-16 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 30 residents reviewed (Residents 4, 5, 11). Findings include: The facility's policy for medication administration, dated July 11, 2025, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered, and if the medication is a controlled substance, staff are to sign the narcotic book. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 17, 2026, revealed that the resident had moderated cognitive impairment, requires assistance from staff and had diagnoses that included arthritis (inflammation, pain, and stiffness in one or more joints), and Parkinson's Disease (progressive neurodegenerative disorder that causes tremors and rigid limbs).Physician's orders for Resident 4, dated February 10, 2026, included an order…

  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 · D2026-04-16 · tag F0557 — isolated
  Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 30 residents reviewed (Resident 100) who had an indwelling urinary catheter.Findings include:Review of admission records for Resident 100 revealed she was admitted to the facility on [DATE], with a diagnosis of aftercare following joint replacement surgery and had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). Observations of Resident 100 on April 15, 2026, at 12:08 p.m. revealed that the Resident was sitting in her wheelchair on the left side of her bed eating her lunch. Her urinary catheter drainage bag was attached to the bed frame on the left side of her bed, visible form the Resident's doorway, with no privacy bag on the urinary drainage bag and yellow urine visible in the bag. Interview with Registered Nurse 1 on April 15, 2026, at 12:11 p.m. confirmed that there was no dignity or privacy bag on the Resident 100'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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-16 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent 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

  Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions and informed consent were implemented prior to initiation of an antipsychotic medication for one of 30 residents reviewed for unnecessary medications (Resident 2).Findings included: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated July 11, 2025, indicated that psychotropic medications are not used unless clinically indicated, are prescribed at the lowest effective dos, and are subject to gradual dose reduction and behavioral interventions in accordance with federal regulations and informed consent will be obtained per state law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 6, 2026, revealed that the resident is cognitively…

  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
• Potential for harm · Dcited before2026-04-16 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for two of 30 residents reviewed (Residents 100 and 105). Findings include:A facility policy for Care Planning dated July 11, 2025, indicated that the licensed nurse will initiate a baseline care plan upon admission to facility and complete within 48 hours. On the first business day following admission the licensed nurse will review and update the care plan and complete a comprehensive care plan. Review of admission records for Resident 32 dated April 11, 2026, revealed that the resident was admitted to the facility for aftercare following a joint replacement and she had a foley catheter (a flexible tube inserted into the bladder to drain urine) in place. Observations of Resident 100 on April 13, 2026, at 10:58 a.m. revealed the resident lying in bed with a urinary drainage bag visible, hanging on the right side of the Resident's bed frame. Observations 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 · Dcited before2026-04-16 · 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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 30 residents reviewed (Residents 5 and 42). Findings include: A facility policy for Comprehensive Care Planning, dated July 11, 2025, included that all residents will have a comprehensive care plan that provides guidance to the interdisciplinary team related to care needs, and when appropriate, discharge plans and goals. Care plans will be updated by the licensed nurse and interdisciplinary team as needed with changes. The licensed nurse will make every effort to update the care plan within 24 hours of changes. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 5 dated March 9, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included fusion of the spine and had surgical…

  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 before2026-04-16 · 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 review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of a change in condition and obtain physicians orders for one of 30 residents reviewed (Resident 2).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 2 dated February 6, 2026, revealed that the resident is cognitively impaired, requires assistance with daily care needs and has medical diagnoses that include anxiety, depression, gastrostomy status (a tube inserted into the stomach to provide…

  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 before2026-04-16 · 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 reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders after a change in condition for one of 30 residents reviewed (Resident 54).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated February 20, 2026, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of heart failure.A nursing note dated March 10, 2026, at 3:00 a.m. indicated that the resident felt as though she is falling out of bed and everything is just wrong. An on call practitioner was contacted and orders of orthostatic vitals in the morning.An advanced practice nursing note for resident 54 dated March 10, 2026, at 1:49 a.m. central time, indicated the resident was complaining of the room spinning while lying in bed. The staff were to perform orthostatic vital signs (measurements of blood…

  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 before2026-04-16 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to ensure that an anticoagulant medication was held per physician's orders for one of 30 residents reviewed (Resident 3). Findings include: Facility policy for medication errors, dated July 11, 2025, indicated that the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 15, 2026, indicated that the resident was cognitively impaired and was receiving an anticoagulant (blood thinner). A care plan, dated February 24, 2026, indicated that the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-16 · tag F0770 — failed to provide lab services — isolated
  Provide timely, quality laboratory services/tests to meet the needs of residents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of 30 residents reviewed (Resident 3). Findings include: Facility policy for laboratory tests, dated July 11, 2025, indicated that when a physician has ordered laboratory test for a resident, there will be a systemic way in which that order is processed to ensure accuracy in completion of the order and promote that the physician receives timely results. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 15, 2026, indicated that the resident was cognitively impaired and was receiving an anticoagulant (blood thinner). A care plan, dated February 24, 2026, indicated that the resident had a diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm), and warfarin to be administered as ordered, laboratory tests as ordered, and abnormal results to be reported to physician. Physician's orders for…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-16 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey's ending March 20, 2025, April 8, 2025, August 5, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending April 16, 2026, identified repeated deficiencies related to baseline care plans, develop/implement comprehensive care plan, services provided meet professional standards, quality of care, residents are free of significant med error, pharmacy records, and infection prevention and control. The facility's plan 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.

  Administration 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.

Fines & penalties

$54,240 in federal fines across 5 penalties.

• $14,508 — penalty dated 2025-10-15
• $22,386 — penalty dated 2025-08-05
• $5,782 — penalty dated 2025-03-20
• $5,782 — penalty dated 2025-03-20
• $5,782 — penalty dated 2025-03-20

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

CMS files one row per role, so the 64 rows in the source record cover these 36 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

8 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.

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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA