Pavilion At St Luke Village, The
1000 Stacie Drive, Hazleton, PA 18201 · For profit - Limited Liability company · 120 certified beds · (570) 453-5100 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- it has 2 actual-harm citations
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $90,662 in federal fines (most recent 2025-03-26)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 3 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.
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 | 14.1% | 16.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 9.6% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.6% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.9% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.5% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.0% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 32.5% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.2% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.7% | 68.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 17.2% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.4% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.56 | 1.62 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.12 | 1.18 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 169 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 17.3% 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 52 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 2025Q4 — more than 35% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — 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 | 40.6%CMS range 32.5–48.8 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.4%CMS range 5.9–11.9 | 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 | 17.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 36.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 28.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.4% | 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 | 96.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 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 | 2.9% | 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 | 5.6%CMS range 3.5–8.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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 120 beds and averages 105.3 residents a day — about 88% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 3.02 hrs/resident/day on weekends vs 3.40 on weekdays — 11% thinner on weekends. RN hours go from 0.63 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gdisputed · IDR2026-07-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of facility policies, clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to provide adequate supervision and implement effective, individualized interventions to prevent repeated falls for one of 23 residents reviewed (Resident 104) resulting in actual harm including a subdural hematoma and sacral fracture, requiring hospitalization.Findings include: A review of the facility's Accidents and Supervision policy, last reviewed by the facility on February 12, 2026, indicated the facility would provide each resident with adequate supervision and appropriate assistive devices to prevent accidents. The policy directed staff to identify and assess accident hazards and risks, implement interventions to reduce identified risks, monitor the effectiveness of those interventions, and modify them as the resident's needs or condition changed. The policy indicated that supervision is an intervention used to reduce accident…
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.
- Actual harm · Gcited before2025-03-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a comprehensive review of clinical records, facility policies, and staff interviews, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer for one of 14 sampled residents (Resident CR 1), resulting in actual harm. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions…
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 · F2026-07-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 observation and staff interview, it was determined the facility failed to maintain sanitary food storage and food service practices to prevent contamination and microbial growth (the growth of bacteria, mold, or other microorganisms that can make food unsafe) in the dietary department and failed to ensure that personal resident refrigerators were monitored and maintained at safe storage temperatures to reduce the risk of foodborne illness for two residents of five residents observed on the second-floor nursing unit (Residents 8 and 28).Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department…
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 · F2026-07-17 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on pest control record review, observations, and staff interview, it was determined that the facility failed to implement and maintain an effective pest management program to prevent and control pest activity in the dietary department.Findings include:A review of the facility policy titled Pest Control Policy, last reviewed February 12, 2026, indicated the facility would maintain an effective pest control program to eradicate (eliminate) and contain common household pests and rodents. The policy indicated the facility would maintain a reporting system to address pest issues identified between scheduled visits by the contracted pest management company and would implement appropriate indoor and outdoor pest control measures in accordance with state and federal regulations. A review of the facility's contracted pest management agreement, signed May 23, 2005, indicated the contractor would provide bioremediation (the use of naturally occurring microorganisms to break down grease and organic material that can support insect breeding) to reduce drain fly breeding sites, control…
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 beforedisputed · IDR2026-07-17 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance and providing care in a language that is understood by the resident for 6 out of 23 residents reviewed (Residents 10, 58, 69, 6, 71, and 1) and including experiences reported by 7 out of 9 residents during a resident group interview (Residents 10, 27, 28, 31, 36, 53, 59, 1, and 92). Findings include: A review of the facility policy titled Resident Rights, last reviewed by the facility on February 12, 2026, revealed it is the facility policy that residents have the right to be treated with respect and dignity and the facility will ensure all direct care and indirect care staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. During an interview on July 14, 2026, at 10:15 AM Resident 10 explained that she 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.
- Potential for harm · Ecited beforedisputed · IDR2026-07-17 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, Resident Council meeting minutes, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during resident group meetings, including those voiced by seven of nine residents attending a resident group meeting (Residents 10, 27, 28, 31, 36, 53, 59, 1, and 92). Findings include: A review of the facility's Resident and Family Grievances policy, last reviewed on February 12, 2026, revealed it is the policy of the facility to support each resident's right to voice grievances without discrimination, reprisal, or fear of discrimination. Residents may voice grievances with respect to care and treatment that has been furnished as well as that which has not been furnished, the behavior of staff, and other concerns regarding their long-term care stay. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance. The grievance official, or designee, will keep the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-07-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined the facility failed to transcribe and implement physician orders for eye care hygiene to reduce the risk of infection for one of 23 residents reviewed (Resident 71). Findings include: A clinical record review revealed Resident 71 was admitted to the facility on [DATE], with diagnoses that include blepharitis (a common, chronic inflammation of the eyelids, typically caused by bacterial overgrowth or clogged oil glands at the base of the eyelashes) and a retinal tear of the left eye (a small rip in the light-sensitive tissue lining to the back of the eye). A care plan indicating Resident 71 has a self-care performance deficit related to activity intolerance and impaired balance was indicated on October 28, 2021. Interventions implemented to improve Resident 71's current level of function with activities of daily life include providing the assistance of one staff member for personal hygiene (the ability to maintain one's own cleanliness,…
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 · D2026-07-17 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of clinical records and facility documents, review of select facility policy, and resident and staff interviews, it was determined the facility failed to provide food and beverages consistent with residents' assessed and documented food preferences and intolerances for two residents of 23 residents reviewed (Residents 69 and 58). Findings include: Review of the facility policy titled Dining and Food Preferences, last reviewed by the facility on February 12, 2026, revealed individualized dining, food, and beverage preferences are identified for all residents. The Dining Services Director, or designee will interview the resident or resident representative to complete a food preference interview within 72 hours of admission. The purpose of this interview will be to identify individual preferences for dining location, mealtimes, including times outside of the routine schedule, and food and beverage preferences. The food preference interview will be entered into the medical record. Food allergies, food intolerances, food dislikes and food and fluid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ddisputed · IDR2026-07-17 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff and resident interviews, and select policy review, it was determined the facility failed to assure that smoking paraphernalia was properly secured for one smoking resident to assure the use of these materials were utilized in a safe manner for one resident who smoked (Resident 28).Findings include:Review of the facility's resident smoking policy, last reviewed February 12, 2026, revealed that it was the policy of the facility to provide a safe and healthy environment and that safety protections apply to smoking and non-smoking residents. The policy indicated that smoking was only allowed in designated smoking areas, which are located only on the outside of the building. An interview with the Director of Nursing (DON) on July 14, 2026, at 10:00 AM revealed the facility had one alert and oriented resident deemed an independent smoker, which allowed this resident to maintain control of his smoking paraphernalia (cigarettes, lighters, matches etc.) if safely maintained and safeguarded from unsafe use. Clinical record review revealed that Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-12 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident council meeting minutes, and resident, resident representative, and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of the 22 residents sampled (Residents 5 and 17) and experiences reported by seven out of the 11 residents during a resident group interview (Residents 26, 30, 34, 37, 49, 50, and 69). Findings include: A review of Resident Council meeting minutes dated June 2025 through August 2025 revealed residents raised concerns regarding facility staff failing to respond timely to residents' requests for assistance. A review of the Resident Council meeting minutes dated June 25, 2025, revealed that six residents in attendance were continuing to experience long wait times for care. The issue was marked as unresolved, and a grievance was filed on the residents'…
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 before2025-09-12 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by seven of 11 residents attending a resident group meeting (Residents 26, 30, 34, 37, 49, 50, and 69), and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.Findings include: A review of the facility's policy titled Complaint/Grievance, last reviewed on May 28, 2025, indicated the facility will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The facility will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. The resident should have reasonable expectations of care and services, and the center should address those expectations in a timely,…
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 · E2025-09-12 · tag F0641 — patternEnsure 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 a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS) accurately reflected the status of three residents out of 22 sampled (Residents 1, 4, and 96).Findings include: The Long-Term Care Facility RAI User's Manual (a standardized tool used in long-term care facilities to evaluate residents' strengths and needs),which provides instructions and guidelines for completing the Minimum data Set (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2024, requires the assessment to accurately reflect the resident's status; a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A review of the clinical record 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.
Show the remaining 21 citations
- Potential for harm · Ecited before2025-09-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to thoroughly assess, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice, for one resident out of 22 sampled (Resident 8) and failed to provide person-centered care to meet the clinical needs by failing to monitor intravenous therapy (a way of giving medication or fluids through a needle or tube inserted into a vein) in accordance with professional standards of practice for one of 22 residents sampled (Resident 1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information…
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 · E2025-09-12 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete clinical records for one of 22 sampled residents (Resident 5). Findings include: A clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic kidney disease (gradual loss of kidney function). A physician's order for Resident 5 to receive Cefazolin (an antibiotic medication) sodium injection solution reconstituted to 2.0 g with directions to use 2.0 grams intravenously every eight hours for MRSA (methicillin-resistant Staphylococcus aureus -a type of bacterial infection that can be resistant to antibiotic medications) for 15 days was initiated on August 15, 2025. A review of Resident 5's medication administration record (MAR) dated August 2025…
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 · D2025-09-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect the current needs and services required by one of 22 residents sampled (Resident 96). Findings include: A review of the facility policy entitled Comprehensive Care Plans last reviewed on May 28, 2025, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. A clinical record review revealed Resident 96 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), depression, and anxiety. A…
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 · D2025-09-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, select policy review, and staff interviews, it was determined the facility failed to provide care and services designed to prevent potential complications associated with enteral tube feedings for one resident receiving enteral nutrition out of 22 residents sampled (Resident 8).Findings include: Review of the facility policy titled Enteral Feeding -Enteral Nutrition Pump last reviewed by the facility April 28, 2025, indicated that nurses are responsible for administering enteral feedings (a method of providing nutrition directly into the gastrointestinal tract) when volume control is indicated and as ordered by the physician. The policy further states that closed system enteral feeding containers and tubing can hang safely for up to 48 hours. Clinical record review revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses to include dysphagia (difficulty swallowing), and Alzheimer's disease (a progressive brain disease that destroys memory and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 22 residents reviewed (Resident 98). Findings include: A review of the facility policy titled Trauma Informed Care, last reviewed by the facility on May 28, 2025, revealed it is the policy of the facility to provide care and services that, in addition to meeting professional standards, are delivered using approaches that are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.A review of Resident 98's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful 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 · D2025-03-26 · tag F0895 — isolatedHave a Compliance and Ethics Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, review of facility documentation, and staff interviews, it was determined that the facility failed to effectively implement and enforce its compliance and ethics program in a manner that uses internal controls to more effectively monitor adherence to applicable statutes, regulations, and program requirements, in order to prevent and detect criminal, civil, and administrative violations under the Act, and promote quality of care for two employees identified (Employee 1 and Employee 2) out of two employees employed by the activity department and business office. Findings include: Review of facility's current Code of Ethics manual revealed all employees are required to undergo compliance training on the Code of Ethics as a condition of employment. The principles discussed are mandatory standards and employees must follow the code to remain employed. If an employee knows or suspects a situation is unethical, illegal, or unprofessional, the employee has an obligation to report that suspicion or concern. If an employee knows of a violation and does not report it,…
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 · Fcited before2024-11-21 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
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 the facility's infection control tracking logs and infection control and prevention policy and staff interviews it was determined the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases including scabies for two of 21 residents reviewed (Resident 7 and Resident 54) and failed to maintain an environment conducive to infection prevention. Findings include: A review of the current facility policy for Infection prevention and control, last June 6, 2024, revealed, the infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program…
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 before2024-11-21 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident council meeting minutes, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of 21 sampled (Residents 25 and 74) and experiences reported by five out of the nine residents during a resident group interview (Residents 24, 28, 31, 55, and 57). Findings include: A review of Resident Council meeting minutes dated October 2, 2024, revealed that residents in attendance had concerns regarding call bell response wait times. The meeting minutes contained no further documentation regarding the residents' concerns. A grievance dated October 2, 2024, revealed residents had concerns regarding call bells not answered timely. The document indicated individual concerns would be addressed as needed and reviewed during resident council.…
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 before2024-11-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 a review of clinical records and select facility investigative reports, observation and resident and staff interview it was determined the facility failed to consistently provide care and services to prevent the development of a pressure sore for two residents out of 21 sampled (Residents 19 and 26). Findings include: A review of facility policy titled Unavoidable Pressure Injury, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's risk factors demonstrate they were unavoidable. A clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized…
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 · E2024-11-21 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one out of 21 residents sampled (Resident 74). Findings include: A review of the facility policy titled Restorative Nursing Services, last reviewed by the facility on June 6, 2024, revealed the facility provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition and goals. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted…
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 before2024-11-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policies, and staff interviews it was determined the facility failed to assess and implement individualized measures to meet the toileting needs of one resident out of 21 sampled residents. (Residents 26). Findings included: A facility policy entitled Bladder and Bowel Evaluation last reviewed by the facility June 6, 2024, indicated that residents are evaluated for continence on admission/readmission, quarterly, and with a significant change in status. Residents who are determined to be incontinent without a documented irreversible cause are to be further evaluated for potential bowel and/or bladder management and will have a Bowel and Bladder Evaluation completed and a Bowel and Bladder Elimination Pattern Evaluation completed. Based on the data collected from the patterning evaluation, residents are to be provided an individualized continence management program, a scheduled toileting program, a re-training program, or routine incontinence care which is to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services in acquiring medication to meet the needs of one resident out of 21 sampled (Resident 9). Findings include: A review of facility policy titled, 4.1 New Orders for Controlled Substances, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that all controlled substance orders should be communicated to the pharmacy. If the medication is needed before the next scheduled delivery, facility staff should indicate the exact time by which the medication is needed. If the controlled substance is needed before the pharmacy can make arrangements for a timely delivery, then the facility should fax a request to remove a controlled substance from the emergency medication supply to the pharmacy. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included neuropathy (a nerve condition 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 · D2024-11-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued administration of an antipsychotic medication for one resident out of five sampled residents for unnecessary medication use. (Resident 96). Findings included: A clinical record review revealed Resident 96 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and generalized anxiety disorder (a mental health disorder characterized by the presence of excessive anxiety and worry about a variety of topics, events, or activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 20, 2024, revealed Resident 96 is severely cognitively impaired with a BIMS…
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 · D2024-10-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one of nine residents sampled (Resident 76). Findings include: During an interview on October 16, 2024, at 11:35 AM, Resident 76 indicated the facility is not taking her soiled clothing to the laundry. She explained there have been dirty clothes in the bottom of her closet, and this continues to occur. An observation on October 16, 2024, at 11:35 AM revealed Resident 76's closet had several dirty clothing articles crumpled up on the bottom shelf of her closet. During an interview on October 16, 2024, at 11:40 AM, Employee 1, Licensed Practical Nurse (LPN), indicated the facility washes Resident 76's clothing. She confirmed that worn, soiled, or dirty clothing should be placed in a laundry receptacle and sent to the laundry for cleaning. Employee 1, LPN, confirmed there was dirty clothing in Resident 76's closet and removed the dirty clothing. During an interview on October 16, 2024, at approximately 12:30 PM, the Nursing…
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 before2024-10-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure physician ordered medication, an antibiotic, was timely obtained and administered to treat cellulitis for one resident (Resident 75). Findings include: A review of the facility policy titled Notification of Change in Condition, last reviewed by the facility on May 9, 2024, revealed that the facility will promptly notify the resident, the attending physician, and the resident representative when there is a change in the resident's status or condition. The policy indicates the nurse will notify the attending physician and resident representative when there is a need to alter treatment significantly. Also, the policy states the nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the medical director may be contacted. A clinical record review…
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 · D2024-10-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 a review of clinical records, select facility policies, and staff interview, it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of nine residents sampled (Resident 76). Findings included: A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on May 9, 2024, revealed that antibiotics are to be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy states that staff orientation, training, and education will emphasize the importance of antibiotic stewardship and include how the inappropriate use of antibiotics affects individual residents and the overall community. The training and education will focus on the relationship between antibiotic use and gastrointestinal disease, opportunistic infections, medication interactions, and the evolution of drug-resistant pathogens. A clinical record review revealed that Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-19 · tag F0725 — failed to have enough nursing staff — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, a review of nurse staffing, and grievances filed with the facility, and interviews with staff and residents, it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality care to each resident including eight residents out of 24 sampled (Residents 19, 20, 21, 48, 151, 38, 30 and 85), including concerns expressed in grievances filed with the facility (Resident 85). Findings included: A grievance lodged with the facility dated April 3, 2024, indicated that Resident 48 reported that she was continuously dissatisfied with nursing staff's untimely call bell response time. The facility noted that the grievance is not resolved to the resident's liking, despite facility improvements in staff's call bell response. A grievance filed with the facility dated April 29, 2024, indicated that Resident 85 expressed concerns that staff initially responded to his call bell but left and never came back to get him out of bed as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy, and resident and staff interviews, it was determined that the facility failed to thoroughly assess and evaluate bowel and bladder function, to identify factors for decline, and implement individualized interventions, including timely toileting assistance, to improve bladder and bowel function to the extent possible for one out of 24 sampled residents (Residents 38). Findings include: Review of the facility Bowel and Bladder Evaluation Policy last reviewed May 9, 2024, indicated that residents are evaluated for continence on admission/readmission, quarterly, and with significant change in status. Residents without a documented reversible cause for bowel and bladder incontinence are to have a Bowel and Bladder evaluation completed and Bowel and Bladder Elimination Pattern evaluation completed. Based on data collected from the patterning evaluation residents to be provided an individualized continence management program. Review of Resident 38'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.
- Potential for harm · Ecited before2024-04-09 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement a system to assure timely disposition of resident medications (the process of returning and/or destroying unused medications) to prevent loss and potential drug diversion. Finding include: Review of facility policy entitled, Disposal/Destruction of Expired or Discontinued Mediation, date revised [DATE], revealed that facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations. Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. In Pennsylvania, discontinued and unused medications and medications of discharged or deceased residents shall be immediately removed from the medication cart and brought to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection in one out of two medication rooms (3 rd floor medication room). Findings include: Observation of the facility's third floor medication room on April 9, 2024, at approximately 9:28 AM accompanied by Employee 1 (Licensed Practical Nurse - LPN) revealed a small, dormitory size medication refrigerator located on the floor. Inside the refrigerator observations revealed resident medications were stored along with Observed two plastic, one-gallon containers of iced tea and on the door of the refrigerator were six {6}, 16 fluid oz. bottles of salad dressings. Interview with Employee 1, LPN, on April 9, 2024, at approximately 9:40 AM, confirmed that the food and beverages stored in the medication refrigerator belonged to staff. Interview with the Director of Nursing (DON) on April 9, 2024, at approximately 10:20 AM, confirmed the facility failed to store medication medications under sanitary…
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 · D2023-09-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to accommodate one resident's needs for assistive positioning devices during wheelchair transport of one of three resident reviewed (Resident 74). Findings include: Review of clinical records revealed Resident 74 was admitted to the facility on [DATE], with diagnoses to include aneurysm of carotid artery (a bulge in one of the arteries supplying blood to the brain), muscle weakness and need for assistance with personal care. An admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 22, 2023, indicated that the resident required total dependence of two+ persons physical assist for transfers. Review of the resident's Occupational Therapy Evaluation dated May 16, 2023, revealed that the resident was unable to sit unsupported, and was dependent (requires 100% assist, or 2 or more helpers) for repositioning in a standard…
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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
$90,662 in federal fines across 3 penalties.
- $25,184 — penalty dated 2025-03-26
- $55,419 — penalty dated 2024-07-19
- $10,059 — penalty dated 2023-10-27
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 AVARDIS HEALTH — 38 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.0 | +1.0 vs chain |
| Health inspection | 3 of 5 | 1.9 | +1.1 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 3.2 | +0.8 vs chain |
The other 37 homes this chain runs (chain average 2.0★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GROVE OF HAZEL PARENTCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2025 |
| CITEANTHRA HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2025 |
| PAOP HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2025 |
| HAZLETON RE OWNER, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 05/01/2025 |
| HOBACK, TIFFANY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| MORGAN, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| SNF MGR LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
| CORCORAN, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| JONES, TEQUILLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| LOBITZ, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| MARTUSCELLI, CASSANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
CMS files one row per role, so the 21 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
About 76% 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 $548K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 2026-09-01 — CMS provider number 395265. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-17, 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.