Amoroso Healthcare And Rehabilitation Woodridge
3625 North Progress Ave, Harrisburg, PA 17110 · For profit - Limited Liability company · 95 certified beds · (717) 652-2345 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607) — 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $42,016 in federal fines (most recent 2024-12-13)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 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 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.2% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.3% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.0% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.8% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.2% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 28.1% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.3% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 82.0% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.7% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 19.4% | 25.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.0% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 30.6% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.8% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.1% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.14 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.88 | 1.18 | 1.80 | typical |
§ 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.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 7.0–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 81.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 95 beds and averages 84.1 residents a day — about 89% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.31 hrs/resident/day on weekends vs 3.70 on weekdays — 10% thinner on weekends. RN hours go from 0.50 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 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.
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Kcited before2026-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observations, facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement (Resident 1). Resident 1 exited the building through an unlocked door and was found in the facility's parking lot. This failure placed eight additional residents in an Immediate Jeopardy situation who were identified as an elopement risk (Residents 2, 3, 4, 5, 6, 7, 8 and 9). Findings Include: Review of facility policy, titled Wandering and Elopements, revised March 2019, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-20 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner that enhances his or her quality of life for one of four residents reviewed (Resident 2).Findings Include: Review of the facility's policy, titled Dignity, dated 2001, read, Residents are treated with dignity and respect at all times. Also, Resident goals, choices, preferences, values, and beliefs, are respected and honored.This begins at initial admission and continues throughout the resident's stay. Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). Review of Resident 2's clinical record revealed an admission date to the facility on February 25, 2026. Review of a documented statement, dictated to the Director of Nursing, dated February 26, 2026, revealed that upon admission to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, document review, and staff interview, it was determined that the facility failed to ensure that the services provided met professional standards of quality for two of four resident records reviewed (Residents 1 and 4).Findings Include: Review of the facility's policy, titled Administering Medications, revised April 2019, read, Medications are administered in a safe and timely manner, as prescribed. The policy continued, The individual administering medications verifies the resident's identity before giving the resident his/her medications. Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive, incurable, but treatable inflammatory lung disease causing obstructed airflow) and hypotension (abnormally low blood pressure). Review of Resident 4's clinical record revealed diagnoses that included respiratory failure (a critical condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide) and atrial fibrillation (a common heart condition characterized by an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of clinical records and a staff interview, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice and the comprehensive plan of care for one of four residents reviewed (Resident 2).Findings Include: Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). Review of Resident 2's clinical record revealed a recent hospitalization resulting in surgery to the spine. According to documentation, Resident 2's wound/incision required staples, and the care to the site should be open to air. Review of a document titled Employee Progress Discipline Notification, dated February 26, 2026, revealed that the Nurse Aide (Employee 3) assigned to provide care to Resident 2 was suspended for three days for double briefing Resident 2 with the knowledge that the surgical site needed to be open to air.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 policy review, clinical record review, and staff interview, it was determined that the facility failed to provide routine drugs to its residents and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of the four residents reviewed (Resident 2).Findings Include: Review of the facility's policy, titled' Policy Services Overview, revised April 2019, reads, in part, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The policy continued, Pharmacy services are available to residents 24 hours a day, seven days a week. Also, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency, or as needed) in a timely manner. Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated 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.
- Potential for harm · Ecited before2025-11-26 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident condition for six of 19 residents reviewed (Residents 2, 4, 5, 7, 15, and 32).Findings include: Review of Resident 2's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 4 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (persistent high blood pressure), and schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Review of Resident 2's Annual MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of May 18, 2025, revealed under Section M- Skin Conditions, Resident 2 was marked no to indicate he was not at risk of a pressure ulcer. During an interview with the Director of Nursing (DON) on October 21, 2025, at 1:09 PM, she revealed the aforementioned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for two out of 19 residents reviewed (Residents 4 and 83).Findings include: Review of the facility policy, titled Falls - Clinical Protocol, with a last revised date of March 2018, and a last reviewed date of May 21, 2025, revealed, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-26 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for two of 19 residents reviewed (Residents 4 and 85). Findings include: Review of facility policy, titled Weighing and Measuring a Resident last reviewed May 21, 2025, read, in part, The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Review the resident's care plan to assess for any special needs of the resident. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and three of three pantry areas.Findings include: Review of facility policy, titled Policy: Storage Areas last reviewed May 21, 2025, read, in part, All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All freezer units are always kept clean and in good working condition. Review of facility policy, titled Food from Outside Sources last reviewed May 21, 2025, read, in part, Visitors/family member will label food and beverages with the resident's name, room number, and date. Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility.Observation of the dry storage area on September 29, 2025, at 9:27 AM, revealed one bag of spiral pasta open without an open date, and one bag of elbow pasta open without an open…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 9).Findings include: Review of facility policy, titled Psychotropic Medication Use, with a last review date of May 21, 2025, revealed, in part, Assessment and Evaluation of the Resident: 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. 2. Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include: a. admission or readmission; c. an irregularity identified during the drug regimen review. Behavioral and Other Non-Pharmacological Interventions: 1. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0628 — isolatedProvide 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 facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received a transfer notice with required included information upon transfer/discharge; failed to provide residents with a copy of the facility's bed hold policy for three of four residents reviewed for hospitalization (Residents 8, 12, and 85).Findings include: Review of facility policy, titled Bed-Holds and Returns last reviewed May 21, 2025, read, in part, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of facility policy, titled Transfer or Discharge, last reviewed May 21,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2025-11-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 19 residents reviewed (Residents 18 and 83).Findings include: Review of the facility policy, titled Activities of Daily Living (ADL), Supporting with a last revised date of April 2025, and a last reviewed date of May 21, 2025, revealed 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care including appropriate support and assistance with: mobility (transfer and ambulation). Review of Resident 18's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and hypertension (high blood pressure). Review of Resident 18's comprehensive care plan revealed an ADL care plan with an intervention that Resident 18 requires…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, manufacturer product information, and staff interviews, it was determined that the facility failed to discard expired medications in a timely manner in one of three medication carts reviewed (Unit 2 Cart 4).Findings include: Review of facility policy, titled Medication Labeling and Storage, with a last review date of May 21, 2025, revealed, in part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of facility policy, titled Administering Medications, with a last review date of May 21, 2025 revealed, in part, The expiration/beyond use date on the label must be checked prior to administering. During a medication pass observation on Unit 2 on October 1, 2025, at 9:05 AM, Employee 1 was administering medications from Cart 4. Employee 1 retrieved a house stock bottle of famotidine 10 mg (milligrams) (an over-the-counter medication used to reduce stomach acid) in preparation to administer to Resident 50. Surveyor review of the bottle noted that an open date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0919 — failed to provide a working call system — isolatedMake 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
Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of 19 residents observed (Resident 74).Findings include: Review of the facility policy titled, Answering the Call Light with last revised date of September 2022, and a last reviewed date of May 21, 2025, revealed 4. Be sure that the call light is plugged in and functioning at all times. Review of Resident 74's clinical record revealed diagnosis including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing). Review of Resident 74's comprehensive care plan reveals an ADL (Activities of daily living) care plan with an intervention for the Resident's call bell to be within reach, initiated on July 9, 2018. Observation conducted on September 30, 2025, at 12:30 PM, revealed Resident 74 was lying in bed with no call bell attached to their room or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-24 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide and document sufficient preparation to residents to ensure a safe and orderly discharge from the facility; and failed to provide a discharge summary that included a post-discharge plan of care, including post-discharge services, for one of two discharged residents reviewed (Resident 1).Findings include:Review of facility policy, titled Discharge Summary and Plan, with a last review date of May 21, 2025, revealed, in part, 2. The discharge summary provides necessary information for continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge. 3. By the time the resident leaves the facility, the discharge summary is furnished to the provider who is assuming responsibility for care of the resident after discharge. 4. The discharge summary may be provided in printed or electronic format. If in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-24 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide sufficient and timely social services related to the admission and discharge planning process for one of two residents reviewed (Resident 1).Findings include:Review of facility policy, titled Social Assessment, with a last review date of May 21,2025, revealed, in part, A social assessment shall be completed within fourteen (14) days of the resident's admission to the facility. A social assessment will be done to help identify the resident's personal and social situation, needs, and problems. Social services staff will obtain information during the initial interview of the family and upon the resident's admission. The purpose of obtaining this data is to identify information to help staff develop a personalized plan of care that will utilize the individual ' s existing strengths, try to compensate for physical and functional deficits, optimize function and quality of life, and meet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed (Resident 5). Findings include: Review of Resident 5's clinical record revealed diagnoses that included chronic kidney disease (CKD - a condition where the kidneys are damaged and can't filter blood as they should) and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 5's hospital referral paperwork revealed an assessment/plan on December 17, 2024, for: will need outpatient, in-lab PSG (polysomnography) with BiPAP (a noninvasive ventilator that helps people breathe by delivering pressurized air through a mask) titration. Review of Resident 5's hospital referral paperwork revealed an assessment data on December 17, 2024, for the following: Pulmonary following the patient continue BiPAP at night, continue BiPAP at night and as needed during the day.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-17 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on employee file review, policy review, and staff interviews, it was determined that the facility failed to conduct timely, complete, and accurate background investigations for four of five employee files reviewed (Employee 7, 8, 9, and 11). Findings include: Review of facility policy, titled Hiring, last reviewed August 16, 2024, revealed section 10 stated, Where appropriate, background investigations may be conducted on persons making application for employment with this facility and on current employees as per regulatory guidelines. Review of Employee 7's personnel file revealed that Employee 7 was hired by the facility on August 19, 2024. Review of Employee 7's application submitted to the facility revealed that Employee indicated, Yes, to the question of, Have you ever been convicted of a felony or misdemeanor? Employee 7 did not have anything recorded in the section below the question which stated, If yes, please explain. Review of Employee 7's personnel file revealed the facility completed a criminal background check through the Pennsylvania State Police on August 27,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-17 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 observation, record review, and staff interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders for two of 23 residents reviewed (Residents 22 and 72). Findings include: Review of Resident 22's clinical record revealed diagnoses that included chronic kidney disease (CKD loss of the ability of the kidneys to remove waste and concentrate urine) and congestive heart failure (CHF when your heart muscle doesn't pump blood as well as it should). Review of Resident 22's physician orders revealed an order for Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 Unit/milliliter (Insulin Aspart with Niacinamide) Inject as per sliding scale: If 140-180 = 2; 181-240 = 4; 241-300 = 6; 301-350 = 8; 351-400 = 10; if greater than 400 administer 10 units and call physician, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic polyneuropathy, with an order date of April 29, 2024. Review of Resident 22's July 2024 Medication Administration Record (MAR) revealed on July 1, 2024,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-17 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility document review and staff interviews, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for five of five employees reviewed (Employees 1, 2, 3, 4, and 5). Findings Include: Review of select facility documentation revealed that Employee 1 was hired on November 16, 1999; Employee 2 was hired on January 4, 2019; Employee 3 was hired on March 27, 2007; Employee 4 was hired on September 12, 2011; and Employee 5 was hired on May 1, 2006. On October 16, 2024, at approximately 8:45 AM, the surveyor was provided with performance evaluations for Employees 2, 3, and 5. Review of the performance evaluations revealed they were all dated as being completed on October 15, 2024. No performance evaluations were provided for Employees 1 and 4. On October 16, 2024, at 11:05 AM, the Director of Nursing (DON) stated that the facility has been working on updating the performance evaluations because of the recent change in ownership and they were starting staff with a clean slate. In a follow-up interview with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain a safe and sanitary environment that supports infection prevention and control for seven of 25 residents reviewed (Residents 40, 49, 60, 66, 80, 83, and 86); and failed to maintain an accurate data collection system of infection surveillance from January 2024 through August 2024. Findings Include: Review of facility policy, titled Enhanced Barrier Precautions, with a revision date of March 2024, revealed Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Further review of the policy revealed: 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. a. Wounds generally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility policy review, manufacturer label review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of three residents with tube feedings reviewed (Resident 19). Findings include: Review of facility policy, Enteral Nutrition, revised November 2018, failed to reveal any expectation for labeling an enteral nutrition bottle with the time or date that it was open and placed into use. Review of Resident 19's clinical record revealed diagnoses of abnormal weight loss (unintentional weight loss or weight loss without trying) and feeding difficulties (difficulties eating, chewing, or swallowing). Observation of Resident 19 on October 15, 2024, at 10:14 AM, revealed that the Resident was lying in bed. Beside the Resident's bed was a pole with tube feeding hanging. The tube feeding container was not labeled with the time or date that the tube feeding was opened, or when the administration began. Observation of Resident 19 on October 16, 2024, at 9:52 AM, revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and staff interviews, it was determined that the facility failed to ensure drugs are stored in locked compartments and only accessible by authorized personnel for two of three resident areas observed (100 Hall and 200 Hall). Findings Include: Review of facility provided policy, Disposal of Medications and Medication-Related Supplies, effective July 1, 2023, revealed, all discontinued and unused medications may be disposed of by the facility, and medications to returned to the pharmacy should be secured until the time of pick-up. An observation on October 15, 2024, at 10:11 AM revealed a round, white object on the floor in a resident's room in the 100 Hall. An immediate interview with Employee 6 (Registered Nurse), confirmed the round, white object to be a medication (pill) and stated she would attempt to determine the type of medication. An additional interview with Employee 6 on October 15, 2024, at 12:44 PM, revealed she was unable to determine the name or origin of the medication. An interview with the Director of Nursing (DON) on October 16,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of three residents reviewed for pressure ulcers (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness). Further review of Resident 1's clinical record revealed that she is followed weekly by an outside wound consultant for an unstageable pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to her sacrum (a triangular bone in the lower back). Review of Resident 1's wound consult 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.
- Potential for harm · Dcited before2024-06-24 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), gastro esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), and hypertension (high blood pressure). Review of Resident 1's physicians orders revealed the following medications: Clopidogrel Bisulfate Oral Tablet 75 mg (milligram- unit of measure), give one tablet by mouth one time a day, with a start date of November 13, 2023. Famotidine Tablet 20 mg, give one tablet by mouth one time a day, with a start date of May 25, 2024. Jardiance Oral Tablet 10 mg, give one tablet by mouth one time a day, with a start…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-07 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents pharmacy reviews are acted upon appropriately by the attending physician for four of five residents reviewed for unnecessary medication (Residents 19, 45, 49, and 63) Findings include: Review of facility policy, titled Consultant Pharmacist Reports IIIA1: Medication Regimen Review (Monthly Report), dated 2006, revealed Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident 19's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors). Review of Resident 19's pharmacy recommendation dated July 15, 2023, revealed the consultant pharmacist's recommendation stated, This resident has been receiving Pyridoxine 50 milligrams (mg) twice a day and Valproic Avid 1500 mg once a day 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.
- Potential for harm · Dcited before2023-12-07 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the faciliy failed to ensure the resident assessment was accurate for two of 21 residents reviewed (Residents 10 and 49). Findings include: Review of Resident 10's clinical record on December 5, 2023, at approximately 10:00 AM, revealed diagnoses that included diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood into the cells) and chronic kidney disease stage 4 (severe decrease in the ability of the kidneys to filter toxins from the blood). Review of Resident 10's Quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a residents physical, mental, and psychosocial needs), with an assessment reference date of September 13, 2023, revealed that section N0410 Medications Received, subsection E - Anticoagulants, was coded to reflect Resident 10 had received an anticoagulant medication for seven of seven days of the look-back period. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure services provided meet professional standards of quality and practice for one of 21 residents reviewed (Resident 28). Findings Include: Review of the facility's policy, titled Self -Administration of Medications, revised December 2016, read Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Review of the facility's policy, titled Medication Administration-Preparation and General Guidelines, read Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy continued, Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Also, The resident is always observed after administration to ensure that the dose was completely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-07 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 21 residents reviewed (Resident 9). Findings include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, last revised in March 2018, revealed the following: Resident will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Review of the clinical record for Resident 9 revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During an interview with Resident 9 on December 5, 2023, at 1:32 PM, they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, and staff interviews, it was determined that the faciliy failed to ensure that the resident enviornment was free of accident hazards two of three residents reviewed for falls (Residents 14 and 35). Findings include: Review of Resident 14's clinical record revealed diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and aphasia (loss of ability to understand or express speech, caused by brain damage). Observation made on December 4, 2023, at 9:51 AM, revealed Resident 14 had a fall mat down on the left side of their bed, while the Resident was lying in bed. Observation made on December 5, 2023, at 9:08 AM, revealed Resident 14 had a fall mat down on the left side of their bed, while the Resident was lying in bed. Observation made on December 5, 2023, at 1:48 PM, revealed Resident 14 had a fall mat down on the left side of their bed, while the Resident was lying in bed. Observation made on December 6, 2023, at 10:15 AM, revealed Resident 14 had a fall mat down on the left side 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$42,016 in federal fines across 1 penalty.
- $42,016 — penalty dated 2024-12-13
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MANZELLA, VINCENZO | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/15/2024 |
| SHARP, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2024 |
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 84% 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 $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395142. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-26, 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.