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Kadima Rehabilitation & Nursing At Greenville

110 Fredonia Road, Greenville, PA 16125 · For profit - Corporation · 154 certified beds · (724) 588-8090 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Mar 20251 immediate-jeopardy citation$21,645 in federal fines
Insights

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

Worth asking about
  • 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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $21,645 in federal fines (most recent 2026-01-29)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • about 20% of its spending goes to commonly-owned related companies

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
25 Williamson Rd Ste 109 · (724) 588-3001 · Call to confirm hours
Pharmacy
419 S Main St · (724) 588-3875 · Call to confirm hours
Grocery
419 S Main St · (724) 588-1381 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 3 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased22.9%16.8%15.4%worse
Long-stay residents who lose too much weight5.9%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.6%0.7%0.9%better
Long-stay residents with a urinary tract infection0.2%1.5%2.0%better
Long-stay residents with depressive symptoms5.6%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.7%3.1%3.3%worse
Long-stay residents whose ability to walk worsened22.3%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.3%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine99.0%93.5%95.3%typical
Long-stay residents with pressure ulcers5.7%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control29.2%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.1%17.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication4.0%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine80.2%68.7%79.4%typical
Short-stay residents rehospitalized after admission21.5%22.5%22.6%typical
Short-stay residents with an outpatient ER visit15.3%9.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.521.621.67better
Long-stay outpatient ER visits per 1,000 resident days1.821.181.80typical

§ 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.

50.2% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.2%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
55.9%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 55.9% 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 34 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF50.2%CMS range 35.2–62.151.5%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 5.6–13.910.7%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 discharge55.9%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 discharge52.9%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 discharge52.9%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 identified100.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.5%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 worsened2.3%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 hospitalization6.0%CMS range 2.9–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.681.02Oct 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

0.30
RN hours/ resident / day
0.96
LPN hours/ resident / day
1.91
Aide hours/ resident / day
3.17
Total nurse hours/ resident / day
0.19
RN hoursweekends
53.8%
Total nursing turnover
61.1%
RN turnover

How full it usually is: this home is certified for 154 beds and averages 137.5 residents a day — about 89% occupied, or roughly 16 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.28 on weekdays — 12% thinner on weekends. RN hours go from 0.34 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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

9
deficiencies at the latest standard inspection (2026-06-26)
3
at the previous standard inspection (2025-06-06)

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

Inspection deficiencies

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

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-05-01 · 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 facility policy, facility documents, clinical records, and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide ideations from inflicting self-harm for one of seven residents reviewed with a history of suicide ideation and resulted in an Immediate Jeopardy situation (Resident R1).Findings include: A facility policy entitled, Suicide Threats dated 4/01/26, indicated that:A staff member must remain with the resident until the nurse supervisor/change nurse arrives to examine the resident.Place the resident on one-on-one observation until the acute episode has been resolved if the resident is physically capable of self-injury.The resident shall remain one-on-one until transfer from the facility or nursing assessment has identified that the resident is no longer a safety risk.The charge nurse or designee shall immediately notify the resident's attending physician, and responsible party of record of such threats.The nurse supervisor will notify the resident's attending…

    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 · E2026-06-26 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care as documented on the resident's Pennsylvania Order for Life Sustaining Treatment (POLST - a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) for three of 27 residents reviewed (Residents R14, R38, and R50).Findings include: Facility policy entitled Advanced Directives dated [DATE], indicated that All residents shall be presumed as having consented to CPR (Cardiopulmonary Resuscitation - emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) unless there is documentation in the medical record that the resident has specified that a DNR (Do not attempt resuscitation and allow natural death) order is present on the clinical…

    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 no plan of correction
  • Potential for harm · Ecited before2026-06-26 · 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 and clinical records, observations, and staff interviews, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respirator care equipment for two of five residents reviewed (R14 and R50), and failed to obtain a physician's order for the provision of oxygen therapy for one of five residents reviewed (Resident R15). Findings include: Facility policy entitled Medication and Treatment Orders dated 4/21/26, indicated each medication administration will have a corresponding and complete physician's order and oxygen orders will contain: The rate of flow, route, and rationale (i.e., Oxygen 2-3 L/min [liters per minute] per nasal cannula prn [as needed] for SOB [shortness of breath]). Resident R14's clinical record revealed an admission date of 6/20/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2026-06-26 · 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 review of facility policy and employee handbook, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of one main kitchens and two of two pantry refrigerators checked (Unit 1 and Unit 4), failed to served food in a safe and sanitary manner during tray line observation, and failed to monitor resident's personal refrigerators for temperatures for one of one residents reviewed with personal refrigerator (Resident R121). Findings include: Facility policy entitled Food Storage dated 4/21/26, indicated Un-served leftovers shall be labeled, dated and stored for a period not to exceed there (3) days. Facility policy entitled Storage of Perishable Foods dated 4/21/26, indicated products such as salad greens, celery, radishes, etc, should be cleaned, trimmed, rinsed, and stored in plastic bags. Facility employee handbook section entitled Meals indicated if a lunch is brought and must be refrigerated, it can be put in the refrigerator in the break room. Facility policy entitled…

    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 no plan of correction
  • Potential for harm · D2026-06-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain a clean homelike environment and ensure resident's wheelchairs were in working order for one of four units (Unit 1). Findings include: Facility policy entitled Resident Environment dated 4/21/26, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. Observation on Unit One on 6/23/26, at 2:01 p.m. revealed Resident R116 sitting in his/her wheelchair with dried dirty substance down the right side of the wheelchair and crumbs / debris on the frame of the wheelchair. Observations on Unit One on 6/23/26, at 2:25 p.m. revealed Resident R59 sitting in his/her wheelchair. The left wheelchair brake was not working, left armrest plastic covering was cracked and pealing exposing the foam underneath it, and the right armrest was missing the foam and plastic covering. During an interview on 6/23/26, at 3:34 p.m. the Director of Nursing confirmed that Resident R116's wheelchair was unclean with dried debris noted, and 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 no plan of correction
  • Potential for harm · D2026-06-26 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies, clinical record, and staff interviews, it was determined that the facility failed to provide resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two of three residents reviewed for hospitalization (Residents R12 and R50). Findings include: Facility policy entitled Bed Hold Policy and Procedure dated 4/21/26, indicated that upon discharge from the facility and admission to a hospital, the Social Service Department or the Administrator's designee will contact, by telephone and in writing, the resident/responsible part to inform them that the resident was discharged to the hospital and of the 15-day bed hold, under Medicaid. Resident R12's clinical record revealed an admission date of 7/8/25, with diagnoses that included Breast Cancer, Dementia (loss of cognitive…

    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 no plan of correction
  • Potential for harm · Dcited before2026-06-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical records, and staff and resident interviews, it was determined that the facility failed to obtain a physician's order for the management of a colostomy for one of 27 residents reviewed (Resident R26), and failed to ensure physician's orders were followed for medication administration for one of 27 residents reviewed (Resident R4).Findings include: Review of facility policy dated 4/21/26, entitled Medication Administration revealed Medications are administered in accordance with written orders of attending physicians; The Resident's E-MAR (Electronic Medication Administration Record) is initialed by the person administering a medication in the space provided under the date and on the line for that specific medication dose administration. Documentation is done immediately after the administration and/or refusal of the medication or attempt; The employee who administers medications to residents shall record and sign on the individual medication record 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 no plan of correction
  • Potential for harm · Dcited before2026-06-26 · 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 facility policy, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment related to smoking for one of six residents who smoke at the facility reviewed (Resident R48). Findings include: Facility policy entitled, Smoking Policy, dated 4/21/26, revealed Designated smoking areas have been established outside the building for these residents, staff or visitors who choose to smoke; Smoking restrictions apply to all smoking methods including cigarettes, pipes, cigars and electronic cigarettes; To ensure the safety of all residents, smoking supplies for all residents will be kept locked in the medication cart and provided to the resident upon request. Review of Resident R48's clinical record revealed an admission date of 2/12/26, with diagnoses that included gastro-esophageal reflux disease (GERD-a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), 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 no plan of correction
  • Potential for harm · Dcited before2026-06-26 · tag F0761 — failed to label and store drugs safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly store medications, and failed to properly date two [NAME]-dose vial of Aplisol (an injectable diagnostic solution test to determine if a person has been infected with tuberculosis) in one of three medication storage rooms reviewed (Unit One medication storage room). Findings include: A facility policy entitled Storage of Medications with a policy review date of 4/21/26, revealed Medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed. Review of the manufacturer's instructions for Aplisol revealed, Aplisol vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than 30 days should be…

    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 no plan of correction
  • Potential for harm · Dcited before2026-06-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for one of 27 residents reviewed (Resident R4). Findings include: Review of facility policy dated 4/21/26, entitled Medication Administration revealed Medications are administered in accordance with written orders of attending physicians; The Resident's E-MAR (Electronic Medication Administration Record) is initialed by the person administering a medication in the space provided under the date and on the line for that specific medication dose administration. Documentation is done immediately after the administration and/or refusal of the medication or attempt; The employee who administers medications to residents shall record and sign on the individual medication record of each resident the medication, dosage and time it was given. This shall be done as soon as possible after the medications have been given. Review of facility policy dated 4/21/26, entitled Documentation revealed Nursing documentation will follow…

    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 no plan of correction
  • Potential for harm · Dcited before2026-06-12 · 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to monitor oxygen saturation (a measurement to determine the amount of hemoglobin carrying oxygen in the red blood cells) according to physician orders for one of eight residents reviewed (Resident R1).Findings include: Facility policy entitled Oxygen Administration dated 4/21/26, indicated oxygen therapy will be provided when a resident needs oxygen at a concentration greater than room air.to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Resident R1's clinical record revealed an admission date of 1/28/26, with diagnoses that included congestive heart failure (heart does not pump blood efficiently leading to fluid retention), respiratory failure with hypoxia (respiratory system fails to adequately oxygenate the blood), and chronic obstructive pulmonary disease (a progressive group of lung diseases that cause damage and inflammation in the lungs making it difficult to breath). Residents R1's clinical record…

    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
Show the remaining 16 citations
  • Potential for harm · Dcited before2026-06-12 · tag F0880 — failed to prevent and control infections — isolated
    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 review of facility policy, guidance from the Pennsylvania Department of Health (PADOH), clinical record review, and staff interview, it was determined that the facility failed to implement infection control practices by incorporating transmission-based precautions (infection control measures used in healthcare settings to prevent the spread of highly transmissible pathogens) for the required duration related to a positive Respiratory Syncytial Virus (RSV-a highly contagious respiratory virus that infects the lungs and breathing passages) test for one of eight residents reviewed (Resident R1).Findings include: Review of the facility policy entitled Infection Control Plan, Program, and Committee dated 4/21/26, indicated transmission-based precautions are the second tier of basic infection control and are used in addition to standard precautions (the minimum set of infection control practices used for all patient care in a healthcare setting) for patients who may be infected or colonized with certain infectious pathogens for which additional precautions are needed to prevent…

    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 · Ecited before2026-05-01 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, facility documentation, facility policies, and staff interview, it was determined that the facility failed to maintain complete and accurate records for six of seven residents reviewed (Residents R1, R2, R3, R4, R5, and R6).Findings include:A facility policy entitled, Admission date 4/01/26, indicated that an inventory of all resident valuables will be completed, staff will record the quantity and description of each item, staff and resident/representative will sign the form.Resident R1's clinical record revealed an admission date of 11/19/25, with diagnoses that included stroke, suicidal ideations, and post-traumatic stress disorder [PTSD-mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety].Resident R1's admission checklist lacked documentation that his/her inventory was completed and signed.Resident R1's Inventory of Personal Effects indicated he/she had clothing items, a wheelchair, shaving kit, and phone and charger upon admission to the facility and further review of Resident R1'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 · D2026-05-01 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and self-harm prevention interventions were effectively implemented in the facility. Findings include: The NHA's job description revealed that the NHA's primary purpose is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The DON's job description revealed that the DON's primary purpose is to plan, organize, develop, and direct the overall operations of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the Administrator and the Medical…

    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 · Ecited before2026-03-11 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, manufacturer's guidelines, and clinical records and staff and resident interviews, it was determined that the facility failed to ensure insulin was administered in accordance with good nursing principles and practices for three of 35 residents reviewed (Residents R7, R1, and R2)Findings include: A facility policy, Medication Administration dated 1/20/26, revealed medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications. Manufacturer's guidelines for Humalog (Insulin Lispro) revealed a subcutaneous injection (medication is injected into the fatty tissue beneath the skin) should be administered within 15-minutes before a meal or immediately after a meal. Manufacturer's guidelines for Novolin Regular (Insulin) revealed a subcutaneous injection…

    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 before2026-03-11 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, job descriptions, clinical records, resident council minutes, and grievances, observations, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for eight of 15 residents reviewed (Residents R1, R3, R4, R5, R8, R9, R10, and R11).Findings include: A facility policy entitled Call Light Response dated 1/20/26, indicated that staff will respond to the call light and the resident's needs in a timely manner. A facility job description for a Certified Nursing Assistant and RN Charge Nurse revealed part of their Specific job function is to Answer resident calls promptly and Ensure that residents who are unable to call for help are checked frequently. Part of their Customer Service and Resident Rights is to Ensure that call lights are answered by all employees of the facility regardless of department. If you are not trained to assist with request / need then inform resident that you will seek appropriate personnel…

    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 · E2026-03-11 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately working for one of six halls (500 hall)Findings include: A facility policy entitled Call Light Response dated 1/20/26, revealed that a call bell or alternative device will be placed within the reach of each resident while in their room, toilet, or bathing area. The policy further revealed that staff will be alerted to signals that the call bell is on by the following: Flashing light on intercomBeeping of intercomLighted call signal over the resident's doorSounding of a tap bell During an interview on 3/05/26, at 9:15 a.m. the Nursing Home Administrator (NHA) revealed that the call bell system on Unit 1 had stopped working and a new system was installed and functioning effective 12/10/25. NHA revealed that some residents still utilized a tap bell per their preference. Observations on 3/5/2026, at 1:22 p.m. revealed each resident room had…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-11 · 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 and clinical record and staff interview, it was determined that the facility failed to develop a comprehensive plan of care for one of five residents reviewed (Resident R12).Findings include: A facility policy entitled MDS[Minimum Data Set-a periodic assessment of resident care needs]/RAI/Care Planning dated 1/20/26, indicated the facility will develop a written plan of care individualized for each resident. A facility policy entitled Resident Elopement dated 1/20/26, indicated that any resident with a successful elopement will be reassessed and additional interventions will be identified and included with the Plan of Care. A facility policy entitled Resident Elopement Follow-Up Procedure dated 1/20/26, indicated the plan of care will be modified to incorporate an increased elopement risk and increased monitoring as needed based on behaviors. Resident R12's clinical record revealed an admission date of 11/7/14, with diagnoses that included Paranoid Schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often…

    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 before2026-03-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical record, and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to an incident for one of five residents reviewed (Resident R12).Findings include: A facility policy entitled Documentation dated 1/20/26, indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate and that it will communicate resident's status and provided accurate accounting of care and monitoring provided. A facility policy entitled Resident Elopement dated 1/20/26, indicated that residents shall be reassessed at least quarterly related to elopement risk. Resident R12's clinical record revealed an admission date of 11/7/14, with diagnoses that included Paranoid Schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and disorganized thinking), Diabetes (a health…

    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 before2026-01-29 · tag F0880 — failed to prevent and control infections — isolated
    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 review of facility and clinical records, observations, and staff interview, it was determined that the facility failed to ensure that residents with an indwelling catheter (a tube inserted into the bladder to facilitate urine drainage) receive essential care to help prevent infections for one of eight residents reviewed with an indwelling catheter (Resident R1) Findings include: Review of a current facility policy entitled Catheter Care dated 11/2024, revealed it is the policy of the facility to ensure that residents with an indwelling catheter received appropriate care and maintain their catheter drainage bags and ensure catheter is anchored using strap or other anchoring device and catheter bag is covered and positioned properly. Resident R1's clinical record revealed an admission date of 12/24/25 with diagnoses that included bronchitis (infection of the lungs), hypertension (high blood pressure) and diabetes (uncontrolled blood sugar levels). The clinical record also identified that Resident R1 was currently taking an antibiotic for seven days to treat for a urinary…

    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 · D2025-11-21 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies, resident and staff interviews, it was determined that the facility failed to ensure that mail was delivered unopened to one of nine residents interviewed (Resident R3).Findings include: Review of facility policy entitled, Mail dated 6/2/25, revealed, The resident has the right to privacy in written communications, including the right to send and promptly receive mail that is unopened. Review of a facility policy entitled, Resident Rights dated 6/2/25, revealed, This facility will promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, will be able to assert these rights based on his or her degree of capability. This facility will protect and promote the rights of each resident, including each of the following rights: Exercise his or her rights as a citizen.Privacy and confidentiality.Privacy in sending and receiving mail. During an interview with Resident R3 on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · 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 review of facility policies, clinical records, and staff interview it was determined that the facility failed to clarify physician's orders related to a surgical dressing for one of 13 residents reviewed (Resident R1) and failed to follow physician's orders related to obtaining a Urinalysis and Culture & Sensitivity (UA C&S- a test used to indicate whether or not there is an infection in the urine and what treatment the infection is sensitive to) timely for one of 13 residents reviewed (Resident R2).Findings include: Facility policy entitled Transcribing Physician Orders dated 6/2/25 states, Physician orders will be transcribed when they are received.Questionable treatment orders will be called to the physician for clarification. Resident R1's clinical record revealed an initial admission date of 9/7/25, with diagnoses that included subsequent encounter for fracture with routine healing, encounter for other orthopedic aftercare, and history of falling. Review of Resident R1's clinical record revealed a transfer/admission physician's order regarding the surgical dressing…

    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 · D2025-06-06 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documents, policy and clinical records, and staff interview, it was determined that the facility failed to maintain complete and accurate records relating to dialysis (a medical procedure that filters blood when the kidneys are not functioning properly) communication and failed to ensure medications were administered according to physician's orders for residents receiving dialysis for one of one residents reviewed for dialysis (Resident R18) Findings include: Review of a Memorandum of Agreement signed 2/22/21, between the facility and Dialysis Clinic, Inc. (DCI) revealed the facility shall provide all relevant information to DCI regarding the condition and needs of each resident during his/her dialysis treatment and that DCI shall provide to the facility relevant information regarding each treatment, which may require follow-up care or observation by the facility staff. A facility policy dated 6/2/25, entitled Dialysis Care revealed residents ordered dialysis therapy will be monitored and documentation will be maintained in the medical record and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-06 · tag F0761 — failed to label and store drugs safely — isolated
    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 review of facility policy, observations, and staff interview, it was determined that the facility failed to label one multi-dose vial medication with the resident name, date it was opened, and date it should be used by in one of two medication storage rooms observed (Unit One medication room). Findings include: Review of facility policy entitled Storage of Medications, with a policy review date of 6/2/25, revealed that Medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed. Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are relabeled before storing. Observations of the Unit One medication storage room on 6/6/25, at approximately 11:45 a.m. revealed that one multi-dose vial of Tirzepatide (a prescription medication used to manage type two diabetes and for weight loss in adults) was opened and was currently in use, but 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
  • Potential for harm · Dcited before2025-06-06 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 review of facility policy, observation, and staff interviews, it was determined that the facility failed to monitor resident's personal refrigerators for temperatures for one of one residents reviewed with personal refrigerators (Resident R12). Findings include: A facility policy dated 6/2/25, entitled Personal Refrigerators revealed personal refrigerators are permitted after thorough inspection and will be subject to the same monitoring as other facility refrigerators. The policy further stated that the refrigerator must include a thermometer and will be monitored regularly for temperature compliance. Observation on 6/4/25, at 11:30 a.m. revealed Resident R12 had a personal refrigerator in their room. There was no evidence in the room of a temperature log sheet being present. Observation of the inside of the refrigerator revealed that there was no thermometer to monitor the temperature of the refrigerator. During an interview on 6/4/25, at 11:45 a.m. the Assistant Director of Nursing stated that temperatures for resident's personal refrigerators are documented on each…

    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 · D2025-03-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and clinical records, and staff interview, it was determined that the facility failed to report an incident of serious bodily injury of unknown source for one of one residents reviewed (Resident R1). Findings include: A facility policy entitled Abuse Reporting, dated 11/24, revealed that The Facility shall notify the Department of Health, Department of Aging, and Area Agency on Aging, Adult Protective Services, local law enforcement and licensing agencies depending on the circumstances of the allegation or actual event in compliance with Federal and State regulations, including Act 13. Title 42 Code of Federal Regulations (CFR) §483.12(c) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-18 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policy and resident and staff interviews, it was determined the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable mental and psychosocial well-being by not serving all meals in the dining room daily. Findings include: Review of a facility policy, Serving of Food, dated 1/24/23, stated All residents are encouraged to eat in the dining room/s. During resident interviews on 8/16/23, at approximately 9:00 a.m. and 10:00 a.m. Residents R6, R10, R22, R25, R29, R37, and R49 indicated they enjoy eating their meals in the dining room with other residents, however, the dining room was not open for dinner on the weekdays and all meals on the weekends. During an interview on 8/16/23, at approximately 2:45 p.m. Dietary Staff Employee E8 indicated the residents do not eat in the dining room for certain meals, such as dinner on the weekdays and all meals on the weekends, due to a lack of nursing staff. During an interview on 8/18/23, at approximately 9:50 a.m. the Director of Nursing confirmed 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.

    Nursing and Physician Services 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

$21,645 in federal fines across 1 penalty.

  • $21,645 — penalty dated 2026-01-29

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 KADIMA HEALTHCARE GROUP — 14 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 1 of 51.8-0.8 vs chain
Health inspection 1 of 51.8-0.8 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 3 of 52.5+0.5 vs chain
The other 13 homes this chain runs (chain average 1.8★, 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 / managerTypeRoleSince
KADIMA HEALTHCARE GROUP INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
PINNACLE HEALTHCARE SOLUTIONS INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
DALLAM, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
LOWDEN, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
MORRIS, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
MORRIS-WALKER, AHMADIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
NAYLOR, DIEDREIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
STRAUSS, JONATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
GREENVILLE PROPERTY MANAGEMENT LLCOrganizationADP OF THE SNFsince 11/01/2024
ROMEO, MICHELLEIndividualADP OF THE SNFsince 11/01/2024
THIMONS, DAVIDIndividualADP OF THE SNFsince 11/01/2024

CMS files one row per role, so the 19 rows in the source record cover these 11 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.

3 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.

$8.6M
Net patient revenuemost recent cost report
-27.8%
Operating marginrevenue minus expenses
$2.2M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 85%Medicare 2%Other / private 13%

About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$341per resident / day
operating cost
$10,361per month
≈ monthly operating cost
$267per day
avg. revenue, all payers

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

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 395158. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-26, 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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