Hermitage Nursing And Rehabilitation
500 Clarksville Road, Hermitage, PA 16148 · For profit - Corporation · 105 certified beds · (724) 981-6610 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 | 5 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 improved from 2 to 4 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 | 5.3% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.0% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.2% | 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 | 4.7% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.9% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.3% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.7% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.5% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 63.1% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.4% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.7% | 9.5% | 12.0% | worse |
§ 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.
52.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.2% 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 49 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 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 52.7%CMS range 42.7–63.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.7–15.4 | 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 | 59.2% | 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 | 44.9% | 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 | 49.0% | 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 | 98.5% | 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 | 100.0% | 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 | 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 | 4.5% | 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 | 5.6%CMS range 3.4–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| 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 105 beds and averages 93.4 residents a day — about 89% occupied, or roughly 12 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 2.96 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.78 hrs/resident/day on weekends vs 3.03 on weekdays — 8% thinner on weekends. RN hours go from 0.36 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · Ecited before2025-12-04 · 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 review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two resident refrigerators (Nursing Unit Two); failed to label food brought into the facility with the resident's name and use by date in one of two resident refrigerators ( Nursing Unit Two); failed to maintain sanitary conditions in one of two resident refrigerators (Nursing Unit One); failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher; and failed to prepare food items in accordance with professional standards in the facility's main kitchen. Findings include:Review of facility policy entitled, Food Brought by Family/Visitors with a policy review date of 1/1/25, indicated that Residents/families are asked that containers be labeled with the resident ' s name, the item, and the date. The nursing or housekeeping staff will discard foods that are past their use by / expiration 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 · D2025-12-04 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly 12 hour mandatory trainings for five of five Nurse Aide (NA) records reviewed.Findings include:Review of NA in-service records dated from 10/2024 through 10/2025, revealed that for NA employees the facility did not have evidence of documentation that the required 12 hours of in-service trainings were completed.During an interview on 10/15/25, at 2:30 p.m. the Director of Nursing confirmed that there was no process in place to track in-service training for NAs as required.28 Pa. Code 211.12 (d)(3) Nursing services
- Potential for harm · D2025-09-18 · 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 review of facility policies, clinical records, and shower schedules, and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 13 residents reviewed (Resident R1). Findings include: The current facility policy entitled Resident Care, indicated that facility staff will provide general care as necessary for each resident per their preferences when able, and per physician orders. Residents will be given nursing care and supervision based upon individual needs. Facility policies and procedures, and nursing and other discipline's standards of practice will be utilized to promote physical, mental, spiritual, nutritional, and emotional status of the resident. Residents will be bathed or assisted to shower or bathe routinely and as needed per their preference with foot care given per order/need. A quarterly Minimum Data Set (MDS- periodic assessment of resident's abilities and care needs) Assessment for Resident R1, dated 7/15/25, revealed for Section GG area 0130E self care, ability to shower bathe…
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 before2024-11-15 · 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 review of facility policy, observation, and staff interview, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of two medication rooms reviewed (Unit 1 medication room). Findings include: A facility policy entitled Controlled Substances dated 1/05/24, indicated that all controlled medications must be maintained in a separately locked, permanently affixed compartment. Observation of the refrigerator on Unit 1 medication room revealed a white locked box in the door of the refrigerator. The white locked box containing controlled medications was not permanently affixed to the refrigerator allowing the entire box to be removed from the refrigerator. During an interview on 11/13/24, at approximately 9:02 a.m. Registered Nurse Employee E1 confirmed that the white locked box in the door of the refrigerator contained controlled medications and was not permanently affixed to the refrigerator as required. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code…
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 · D2024-03-21 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, facility grievances, and resident representative and staff interviews, it was determined that the facility failed to resolve a resident representative's grievance concerns related to care/treatment for one of 31 residents reviewed (Resident R1). Findings include: The Concerns-Grievances policy, dated 12/28/23, revealed the facility will honor the resident's right to voice concerns and/or grievances without discrimination or reprisal. Such concerns and/or grievances will include, but not limited to, treatment which has been furnished as well as that which has not been furnished and instances of behavior of other residents. Other forms of grievances could include management of funds, lost items and/or violation of rights. This process will provide a method of documenting Concerns/Grievances and resolutions. These processes combined will promote customer satisfaction with the facility care and services and identify areas of improvement. Social Services will be responsible for coordinating orientation and in-service training to ensure all facility…
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 before2024-02-07 · 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 observations and staff interviews, it was determined that the facility failed to ensure a safe environment for residents residing on two of three units regarding a soiled utility room area (Unit 1 and Unit 2). Findings include: Observations on 2/7/24, at 9:51 a.m. of the soiled utility rooms on Unit 1 with the Housekeeping/Laundry Director, revealed the following: To enter the soiled utility room, observed above the key number entry mechanism were two separate strips of tape with a four digit key code identified on each strip. The numbers were located at a level that any resident could visualize and open the soiled utility room door. The Housekeeping/Laundry Manager utilized the numbers identified on the strip to enter the soiled utility room. Observed inside the room was an uncovered red bag disposal area, a large tote with clear plastic bags with soiled attends and large styrofoam cups, a bag on the floor with dirty linens, and multiple empty boxes piled up from the floor to the countertop. A full gallon of apea care shampoo and body wash was sitting on the counter opened…
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 · E2023-12-21 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, observations, and resident representative and staff interviews, it was determined that the facility failed to develop and implement a comprehensive activity program for one of three resident care units observed (Memory Care Unit Three). Findings include: Review of facility policy Activity Program dated 1/02/23, revealed This facility provides activity programs that are designed to meet the needs of residents with a range of cognitive and physical levels of functioning. 1. Activity programs are designed to encourage individual participation and are geared to the needs and preferences of residents in the facility. 2. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning of the programs, which may include self-directed activities. 3. Our activity programs consist of individual, small and large group activities that are designed to meet the needs and interests of residents and may include such things as: a: exercise, movement to music, pool b: Stimulating activities such as current…
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 · D2023-12-21 · 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
Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to ensure urinary catheter (tube inserted into the bladder to drain urine) care was completed and urinary output was documented per physician orders for one of 20 residents reviewed (Resident R50). Findings include: Review of the facility policy entitled Use and Care of Urinary Catheter Guidelines, dated 1/2/2023, revealed Catheter care will be done per facility policy and as needed. Drainage bags will be emptied every shift and as needed. Review of the facility policy entitled Medication and Treatment Orders, dated 1/2/2023, revealed Treatment orders will be documented in PCC (Point Click Care) and on the Treatment Administration Record (TAR). Resident R50's clinical record revealed an admission date of 3/31/2023, with diagnoses that included chronic kidney disease, retention of urine, and unsteadiness on feet. Review of Resident R50's physician's orders dated 4/01/2023, revealed an order for foley (type of catheter) catheter care every shift and physician'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 · D2023-12-21 · 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
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed (Resident R41), and failed to ensure PRN orders for psychotropic medications be used only when the medication is necessary to treat a diagnosed specific condition for two of five residents reviewed related to psychotropic medication usage (Residents R76 and R85). Findings include: Review of a facility policy entitled Use of Psychotropic Medication dated 1/2/2023, revealed that PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for 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 · Dcited before2023-12-21 · 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 — the official record, unedited, may be distressing
Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin (medication to treat elevated blood sugar levels) and tuberculin solution (used to test for the disease tuberculosis) with the date they were opened in one of three medication carts (Long Cart 2). Findings include: Review of a facility policy entitled, Administering Medication dated 10/01/23, indicated that that the date opened shall be recorded on the container. Observation on 12/18/23, at 3:32 p.m. of the Long Cart 2 revealed an opened multi-dose vial of Novolog insulin without a date when it was opened. At that time, Licensed Practical Nurse Employee E1 confirmed that the multi-dose vial of Novolog insulin did not identify an opened date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies
Show the remaining 7 citations
- Potential for harm · Dcited before2023-12-21 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure food was stored and prepared in a safe and sanitary manner related to the walk-in freezer, dry storage area, cooking equipment, and fans in the dishwashing area for one of one main kitchens. Findings include: Review of a facility policy entitled, Sanitary Conditions dated 1/02/2023, revealed that All equipment will be maintained in a clean and sanitary fashion. Observations conducted on 12/18/2023, at approximately 10:05 a.m. of the main kitchen revealed dirt and debris on the walk-in freezer floor, visible dust, debris, and food on the dry storage room floor, visible grease, and debris on the stove and overhead vents, and two fans in the dishwashing area with a thick layer of dust and a fuzzy substance. During an interview on 12/18/2023, at the time of the observations the Kitchen Manager confirmed that there was dirt and debris on the walk-in freezer floor, visible dust, debris, and food on the dry storage room floor, visible grease, and debris on the stove…
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 · E2023-08-08 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies and staff interviews, it was determined that the facility failed to provide a clean, comfortable and homelike environment for seven of 53 rooms (Rooms 51, 33, 34, 35, 37, 39, and 40.) Finding include: Review of facility policy entitiled, The 5 Step Daily Patient Room Cleaning dated 1/01/23, revealed the entire floor must be dust mopped . Observations conducted between 10:06 a.m. through 10:40 a.m. revealed the following: room [ROOM NUMBER] had loose debris under resident beds room [ROOM NUMBER] had loose debris under the bed by the door room [ROOM NUMBER] had loose debris noted on the resident floors room [ROOM NUMBER] had loose debris noted on the floor room [ROOM NUMBER] had a Kleenex box wedged under the window bed room [ROOM NUMBER] had debris on the floor and under the door bed Observations of rooms on Unit Three on 8/08/23 at 10:43 a.m. revealed that Housekeeper Employee E2 was cleaning resident rooms. During an interview at that time, Housekeeper Employee…
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 before2023-08-08 · 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 observations, review of clinical records and facility documentation, manufacturer's recommendations and staff interview, it was determined that the facility failed to ensure a safe environment for individuals care planned for elopement with alpha tags (device placed on resident to notify staff when resident is exiting the building) for three of three residents reviewed. (Residents R1, R2 and R3) Findings include: Review of manufacturer's recommendations Wander Control Systems Troubleshooting Tips for Testing RF(alpha) tags revealed we highly recommend testing the resident RF (alpha tag) tags every morning with a hand held tag tester. 4 .Tags should never be attached to wheelchairs. Review of Resident R1's clinical record revealed an admission date of 9/08/22, with diagnoses that included seizures, bipolar disorder (periods of depression and elevated mood), multiple sclerosis (disease that affects the nervous system) and anxiety. Review of a physician's order dated 1/05/23, revealed an order for an alpha tag to wheelchair due to increased elopement risk for Resident R1.…
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 · D2023-08-08 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records and staff and resident interviews, it was determined that the facility failed to provide the appropriate number of staff to provide the care and services in assisting residents with showers for two of seven residents reviewed. (Residents R4 and R5) Findings include: Review of Resident R4's clinical record revealed an admission date of 8/10/22, with diagnoses that included high blood pressure, heart problems and stomach reflux. The 6/12/23, Quarterly Minimum Data Set (MDS-periodic review of resident care needs) Assessment revealed that Resident R4 was alert and oriented. The MDS also identified that choosing a bathing method was somewhat important to the resident and bathing required one person physical assist. During an interview on 8/08/23, at 1:33 p.m., Resident R4 stated that they had received their shower recently but had a span of time that they had not gotten a shower. The resident identified that Mondays and Thursdays were their shower days. Review of the bathing record revealed Resident R4 had not received a shower between 7/10/23 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.
- No harm found · B2024-11-15 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to send copies of notice of emergency transfer to the representative of the Office of State Long-Term Care (LTC) Ombudsman for four of four residents reviewed (Residents R18, R37, R56, and R88). Findings include: A facility policy entitled Transfer and Discharge (including AMA-[against medical advice]) dated 1/5/24, indicated the facility will provide copies of notices for emergency transfers to the Ombudsman, when practicable, such as in a list of residents on a monthly basis. Policy also indicated the facility will maintain evidence that the notice was sent to the Ombudsman. Resident R18's clinical record revealed an admission date of 12/16/19, with diagnoses that included stroke, dementia (loss of cognitive functioning affecting a persons memory and behaviors), chronic kidney disease (a gradual loss of kidney function). Departmental notes indicated that Resident R18 was transferred 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.
- No harm found · B2024-11-15 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for four of four residents reviewed for hospitalizations (Residents R18, R37, R56, and R88). Findings include: A facility policy entitled Transfer and Discharge (including AMA-[against medical advice]) dated 1/05/24, indicated for emergency transfers / discharges the facility will provide a notice of transfer and the facility's bed-hold policy to the resident and representative. A facility policy entitled Bed Hold Notice Upon Transfer dated 1/05/24, indicated that in the event of an emergency transfer of a resident, the facility will provide within twenty-four hours written notice of the facility's bed-hold policies. Resident R18's clinical record revealed…
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.
- No harm found · B2023-12-21 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and resident representative for four of 20 residents reviewed (Residents R50, R41, R86, and R89). Findings include: Review of a facility policy entitled, Baseline Care Plan dated 1/02/2023, revealed A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: The initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Resident R50's clinical record revealed an admission date of 3/31/2023, with diagnoses that included chronic kidney disease, retention of urine, and unsteadiness on feet. Resident R50's clinical record lacked evidence that a written summary of the baseline care…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to EMBASSY HEALTHCARE — 33 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 | 2.4 | +0.6 vs chain |
| Health inspection | 4 of 5 | 2.1 | +1.9 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 32 homes this chain runs (chain average 2.4★, 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 |
|---|---|---|---|---|
| EMBASSY PA TENTANT HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2020 |
| EMBASSY HEALTHCARE HOLDINGS INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 05/01/2020 |
| HANDLER, AARON | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2020 |
| REPCHICK, GEORGE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2020 |
| EMBASSY HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2020 |
| HERITAGE EMPLOYMENT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2020 |
| GEORGE, GREGORY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2020 |
| MOODY, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2020 |
CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
This home reported $423K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 395231. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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.