Garvey Manor
1037 South Logan Boulevard, Hollidaysburg, PA 16648 · Non profit - Corporation · 132 certified beds · (814) 695-5571 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $40,641 in federal fines (most recent 2024-08-01)
- its facility-reported quality-measure score sits well above its independent inspection score
- nursing-staff turnover (60%) runs well above the national median (45%)
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 | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 | 19.2% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 6.2% | 5.4% | better |
| 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 | 1.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.2% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.2% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.5% | 17.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 24.8% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 23.1% | 25.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.1% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.7% | 68.7% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.89 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.70 | 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.
33.4% 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 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.19 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 10% 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 | 33.4%CMS range 22.9–50.8 | 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 | 10.0%CMS range 6.8–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 3.9–15.8 | 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 132 beds and averages 127.5 residents a day — about 97% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.73 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.97 hrs/resident/day on weekends vs 4.70 on weekdays — 16% thinner on weekends. RN hours go from 0.72 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2024-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to assess a resident for safety in a chair after a known history of falls from the chair, resulting in a fall with fracture for one of 39 residents reviewed (Resident 2), and failed to follow fall prevention interventions for one of 39 residents reviewed (Resident 5) who had a history of falls. Findings include: The facility's policy regarding accidents and incidents, dated July 2, 2024, revealed that if a fall is involved the resident must be assessed by the professional (registered) nurse supervisor and additional assessment as appropriate. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 13, 2023, indicated that the resident was sometimes understood and could sometimes understand others, required extensive assistance of one for ambulation and transfers, and extensive assistance of one for bathing and toileting. A nursing note for Resident 2, dated November 12, 2023. at 4:14 p.m.,…
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 · D2026-06-04 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for one of 43 residents reviewed (Resident 47). Findings include: A facility policy related to psychotropic medications, dated June 20, 2025, indicated that once it is determined that a psychotropic medication will be initiated and/or increased, the resident and/or representative will be informed of the rationale for the medication order, the benefits/risks associated with the medication use, and of alternatives for the medication. Consent for use of and the education of the resident and/or resident representative regarding the medication order must be documented in the medical record prior to initiation of the medication. Informed consent will be documented in the medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · 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
Based on review of facility policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 43 residents reviewed (Resident 21). Findings include: A review of a facility policy regarding physical and functional needs, dated June 20, 2025, indicated that call bells are always kept within reach of the resident unless otherwise indicated in their plan of care. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 21, dated March 26, 2026, indicated that the resident was usually able to make herself understood and could usually understand others, had cognitive impairment, required moderate assistance from staff for transfers from bed/chair and chair/bed and toilet transfers, required moderate assistance from staff with ambulating, had a fall since the previous assessment without injury, had a motion sensor alarm used daily and had diagnoses that included dementia and orthostatic hypotension (low…
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 · D2026-06-04 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the attending physician and legal representative was notified concerning a change in condition for one of 41 residents reviewed (Resident 53). Findings include: The facility's policy for Change in Condition Reporting, dated June 20, 2025, indicated that the facility shall promptly notify the resident, his/her attending physician and legal representative of changes in the resident's conditions and/or status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated March 23, 2026, revealed that the resident was cognitively impaired, dependent on staff for his daily care needs, and had diagnoses of benign prostatic hyperplasia (a non-cancerous condition that causes the prostate to enlarge and obstruct urine flow). A care plan for Resident 53, dated August 12, 2024, indicated that Resident 53 had the potential for complications with urinary elimination and required…
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 · D2026-06-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect for one of 43 residents reviewed (Resident 6). Findings include: A facility policy regarding abuse reporting, dated June 20, 2025, indicated that all covered individuals (owner, personnel, volunteers, agents and contractors) must promptly report any incident or suspected incident of resident abuse, neglect, exploitation, including injuries of an unknown source suspected to be abuse, misappropriation of resident property, and any actions toward a resident which may be considered a crime by local or state laws. An injury should be classified as an injury of unknown source when both of the following criteria are met: the source of the injury was not observed by any person or the source could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · 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
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 43 residents reviewed (Residents 1 and 6).Findings include: A facility policy regarding care plans, dated June 20, 2025, indicated that resident care plans are reviewed or modified at least quarterly or upon a significant change in the resident's condition, or according to the target date indicated on the care plan. When immediate need care plan problems resolve or stabilize, the immediate need care plan may be resolved or incorporated into the core care plan. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 13, 2026, revealed that the resident was cognitively intact, wore hearing aids, understood and could understand others, required assistance with care needs, had diagnoses that included end stage renal disease and received dialysis (filtering the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 43 residents reviewed (Resident 9), and failed to ensure that psychiatric recommendations for medication changes were completed timely for one of 43 residents reviewed (Resident 47). Findings include: The facility's arm and leg protectors' policy, dated June 20, 2025, indicated that staff should follow physician's orders for arm and leg protectors. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 9, dated May 14, 2026, revealed that the resident was understood and could understood and was severely cognitively impaired. The resident's care plan, dated March 13, 2026, revealed that the resident was to always wear leg protectors except for during hygiene care to help prevent skin breakdown related to impaired skin integrity. Physician's orders for Resident 9, dated February 25, 2023, included an order for the facility to use protocols as indicated to prevent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of a wound that progressed to a pressure ulcer, failed to ensure treatments were in place to prevent the progression of pressure ulcers, and failed to ensure that pressure ulcer treatments were completed as ordered for one of 43 residents reviewed (Resident 6). Findings include: Review of a facility policy regarding wound management program, dated June 20, 2025, indicated that all wounds, skin abnormalities, pressure ulcers/injuries, non-pressure related ulcers/injuries, and surgical wounds shall be identified, assessed, treated, and monitored to promote healing and prevent infections. All pressure ulcers/injuries, non-pressure related ulcers, and/or wounds will have ongoing evaluation by the interdisciplinary team and/or the in-house wound physician. The team leader will complete a skin observation tool under the assessment tab in the medical record. This tool is then printed and given to the Registered Nurse (RN) supervisor for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · 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 review of policies, as well as review of clinical records and staff interviews, it was determined that the facility failed to ensure that neurological checks were completed per facility policy for a resident who sustained a head injury after a fall for one of 43 residents reviewed (Resident 24), and failed to ensure the environment remained as free from accident hazards as possible, by not completing elopement risk assessments quarterly per facility policy for one of 43 residents reviewed (Resident 115). Findings include: A facility policy related to neurological status monitoring, dated June 20, 2025, indicated that the neurological status of a resident will be monitored following suspected head trauma/injury. Parameters will be monitored every 15 minutes for two hours, every 30 minutes for two hours, every one hour for four hours, then every eight hours for 16 hours until 24 hours have passed, unless otherwise ordered by the physician. Neurological flow sheets found to be incomplete will result in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-04 · 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder) for two of 43 residents reviewed (Residents 47, 92). Findings include: The facility's policy regarding urinary catheters, dated June 20, 2025, indicated that the purpose of the policy was to ensure safe handling of the urinary catheter in order to reduce the risk of urinary tract infections. This would include ensuring that the catheter bag is in a catheter bag cover/dignity bag, and that the dignity bag and catheter tubing are off the floor. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated March 11, 2026, indicated that the resident was cognitively impaired, was dependent of staff for daily care needs, had an indwelling urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-04 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 43 residents reviewed (Resident 6). Findings include: A facility policy regarding controlled substances, dated June 20, 2025, indicated that when a controlled substance (C2-C4) is removed for administration and must be destroyed, the destruction and documentation must be witnessed by two licensed nurses. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 4, 2026, revealed that the resident was cognitively intact, received routine and as needed pain medication, received opioid medications (a controlled pain medication), and had a diagnosis of cancer. Physician's orders for Resident 6, dated February 19, 2026, included an order for the resident to receive 50 micrograms (mcg) of Fentanyl transdermal patch (a controlled pain medication administered through the skin) 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.
Show the remaining 20 citations
- Potential for harm · D2026-06-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to date insulin pens in one of three medication carts reviewed (C1 medication cart).Findings include: A facility policy regarding medication storage, dated [DATE], indicated that multi-dose injectables would be discarded per manufacturer's recommendations or one year from the date opened, whichever is less. If a specific expiration date for a particular drug was indicated, a sticker with date opened-date expired will be attached and filled out by nursing or pharmacy when appropriate. (Novolog, Novolog mix, and Lantus insulin vials: 28 days once opened. Novolin R, Novolin N, Novolin 70/30: 42 days once opened.)Physician's orders for Resident 17, dated [DATE], included an order for the resident to receive 24 units of Novalog Mix 70/30 subcutaneously with meals for diabetes mellitus (a chronic disease that causes high blood sugar levels).Observations of the C1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · 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 — the official record, unedited, may be distressing
Based on facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored under sanitary conditions. Findings include:A facility policy regarding food storage June 20, 2025, revealed that food storage areas shall be maintained in a clean, safe, and sanitary manner.Observations in the walk in cooler area on June 1, 2026, at 9:23 a.m. revealed that there was a metal cart with two trays of red velvet cake with white icing. The metal cart was uncovered on one side, and the two trays of cake were not covered and exposed to air. There was a box of packaged sliced red onions. The manufactures' used by date was May 28, 2026. Interview with the Dietary Manager on June 1, 2026, at 9:25 a.m. revealed Interview with the Dietary Director at the time of the observation confirmed that rack cover should have been in place, and the sliced onions should have been discarded. The onions were special food for Memorial Day. 28 Pa. Code 211.6(f) Dietary Services.
- Potential for harm · D2026-06-04 · 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 review of established infection control guidelines and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of 43 residents reviewed (Resident 1,4). Findings include: CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance…
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 · E2025-07-24 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and information provided by the facility, as well as observations and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.Findings include:The facility's policy regarding food temperature records, dated June 20, 2025, revealed that the temperatures of foods shall be taken prior to service. Breakfast temperatures were checked by the cook in the kitchen to assure the food is at proper temperature. Any hot foods falling below established standards of 165 degrees Fahrenheit (F) would be reheated to the proper temperature.An annual minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 6, dated July 8, 2025, indicated that the resident was able to understand others, was understood by others, had clear speech, and was cognitively intact.Interview and observations with Resident 6 on July 21, 2025, at 12:20 p.m., revealed that she eats in her room and the eggs taste like plastic.The posted breakfast menu on July 23, 2025, was juice of choice, hot…
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 before2025-07-24 · 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 — the official record, unedited, may be distressing
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to ensure hair was properly covered with a hair restraint.Findings include:The facility's policy regarding dietary operations, dated June 20, 2025, revealed that hair and beard restraints would be worn while working in the kitchen.Observations in the facility's kitchen on July 21, 2025, at 9:24 a.m. revealed that Dietary Aide 10 was in the kitchen working and had uncovered facial hair. Interview with Dietary Director at that time confirmed that Dietary Aide 10 should be wearing a beard restraint. 28 Pa. Code 211.6(f) Dietary services
- Potential for harm · D2025-07-24 · 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 — the official record, unedited, may be distressing
Based on observations and staff interviews it was determined that the facility failed to keep a clean, homelike environment on the D1 wing. Observations on July 21, 2025 at 11:15 a.m., July 22, 2025 at 9:32 a.m., and July 23, 2025 at 10:18 a.m. revealed that the D1 hallway carpeting and the D1 lounge carpeting had large brown and black stains. Interview on July 23, 2025 at 11:10 a.m. with the Director of Maintenance revealed that the carpeting on D1 and in the D1 lounge needs replaced and that despite the effort of the housekeepers to keep the area clean, the carpet is stained in multiple places.
- Potential for harm · D2025-07-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies, investigation reports, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 41 residents reviewed (Resident 122). This deficiency is being cited as past non-compliance.The facility's policy dated June 20, 2025, regarding prevention of abuse, neglect, misappropriation of resident property and exploitation states that systems are in place to prevent resident abuse, including neglect, exploitation, and misappropriation of property.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 122 dated June 4 2025, revealed that the resident was alert with confusion, required total assistance from staff for her daily care needs, and had diagnoses that included dementia, encephalopathy (condition where the brain does not function properly), and sepsis (serious infection in the blood).Resident 122's care plan, dated May 29, 2025, indicates that the resident exhibited physical/verbal aggression to staff 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 · D2025-07-24 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies and employee files, as well as staff interviews, it was determined that the facility failed to ensure that license checks were obtained prior to hire for two of two Registered Nurses (Registered Nurses 5 and 6).The facility's policy regarding protection from abuse, dated June 20, 2025, indicated that policies and procedures were developed to aid in preventing abuse, neglect, or mistreatment of residents, and protocols for conducting employment background checks and screening of employees.The personnel file for Registered Nurse 5 revealed a start date of June 9, 2025, with a license check done on July 23, 2025. There was no documented evidence that a license check was obtained prior to the staff's start date of June 9, 2025. The personnel file for Registered Nurse 6 revealed a start date of May 27, 2025, with a license check done on June 6, 2025. There was no documented evidence that a license check was obtained prior to the staff's start date of May 27, 2025.Interview on July 23, 2025, at 2:32 p.m. with the Director of Nursing revealed that Registered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy, clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement an individualized care plan for fall prevention for one of 41 residents reviewed (Resident 12). Findings include:Facility policy for safety alarms dated June 20, 2025, revealed that alarms will be used to alert staff to assist residents who have a history of transferring unassisted and when it has been determined that staff assistance is necessary for resident safety.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated July 2, 2025, indicated that the resident was alert and oriented, required maximum assistance for daily care, had a diagnosis of a hip fracture, and utilized a motion sensor alarm less than daily.Resident 12's care plan for fall safety, dated July 8, 2025, revealed that the resident required a motion sensor alarm at the foot of the bed at all times when the resident is in bed.A nursing note for Resident 12 dated July 9, 2025, revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-24 · tag F0729 — isolatedVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies and employee files, as well as staff interviews, it was determined that the facility failed to ensure that Pennsylvania Nurse Aide Registry checks were obtained prior to hire for two of two Nurse Aides reviewed (Nurse Aides 8 and 9).The facility's policy regarding protection from abuse, dated June 20, 2025, indicated that policies and procedures were developed to aid in preventing abuse, neglect, or mistreatment of residents, and protocols for conducting employment background checks and screening of employees.The personnel file for Nurse Aide 8 revealed a start date of May 27, 2025, with a Pennsylvania Nurse Aide registry check done on June 10, 2025. There was no documented evidence that the registry check was obtained prior to the staff's start date of May 27, 2025. The personnel file for Nurse Aide 9 revealed a start date of April 7, 2025, with a Pennsylvania Nurse Aide registry check done on July 23, 2025. There was no documented evidence that the registry check was obtained prior to the staff's start date of April 7, 2025. Interview on July 23, 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 · Dcited before2024-08-01 · 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
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide a reasonable accommodation of needs by failing to ensure that the call bell was within reach for one of 39 residents reviewed (Resident 57). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated April 30, 2024, indicated that the resident was understood and could usually understand others, and she required minimal assistance of staff for care. The resident's care plan, dated January 9, 2024, included that staff were to encourage her to use her call bell for assistance, and the call bell would be placed within reach when the resident is in her room. A therapy note, dated July 28, 2024, revealed that Resident 57 was to have supervision with ambulation and transfers. Observations of Resident 57 on July 29, 2024, at 11:03 a.m. revealed that the resident was sitting on her bed attempting to ambulate, and her call bell was behind her nightstand on the floor and out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 39 residents reviewed (Residents 45, 89). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section O0100 was to be completed with the resident's special treatments, procedures, and programs, and Section O0100C was to be coded for the use of oxygen. Column (1) was to be checked if oxygen was used while not a resident of the facility within the last 14 days, and column (2) was to be checked if oxygen was used while a resident of the facility within the last 14 days. A care plan for Resident 45, revised on November 9, 2023, indicated that the resident had an altered respiratory status related to a history of aspiration (food or liquid entering the lungs) and sleep apnea…
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 before2024-08-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to develop an individualized care plan for diabetes mellitus and/or comfort care for two of 39 residents reviewed (Residents 69, 88). Findings include: The facility's policy regarding care plans, dated July 2, 2024, revealed that care plans will be developed that include measurable goals and timeframes, and must describe the services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs identified in the comprehensive assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated May 8, 2024, revealed that the resident was usually understood and could usually understand, was cognitively intact, dependent on staff for care, had diagnoses that included diabetes mellitus, and received insulin (a medication for the treatment of diabetes mellitus). A review of Resident 69's clinical record, including the medication…
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 before2024-08-01 · 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
Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 39 residents reviewed (Residents 88, 103). Findings include: The facility policy for care plans, dated July 2, 2024, indicated that care plans are to evaluated and revised every 90 days, annually, and if there is a change in a resident's condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated July 9, 2024, revealed that the resident was cognitively intact and required extensive assistance from staff for her daily care needs and had a diagnosis of cerebrovascular disease. Physician's orders for Resident 88, dated April 12, 2024, included an order to discontinue the use of Keppra oral solution 100 mg/ml (a medication to control seizures dispensed in milligrams per milliliter). A review of care plans for Resident 88, dated May 28, 2020, included a care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to obtain physician orders for pacemaker checks for two of 39 resident reviewed (Residents 36, 97) and failed to ensure that an assessment was completed by a professional (registered) nurse after an elopement occurred for one of 39 residents reviewed (Resident 99). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's policy regarding pacemaker rate checks, dated July 2, 2024, indicated that at the time of admission, the registered nurse supervisor would obtain an order for a pacemaker rate check. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure neurological checks were completed following an unwitnessed fall for one of 39 residents reviewed (Resident 99). Findings include: The facility's policy for unwitnessed falls, dated July 2, 2024, indicated that resident falls were to be reported, their causes identified when possible, timely interventions established to help reduce the probability of repeated incidents, and neurological checks (a neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) were to be completed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 99, dated March 8, 2024, revealed that the resident was sometimes understood and sometimes could understand others, required substantial assistance with daily care needs, and had a diagnosis of Parkinson's disease (a disorder of the central…
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 before2024-08-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that devices for pressure relief were in place as ordered by the physician for one of 39 residents reviewed (Resident 89). Findings include: The facility's policy regarding pressure injuries care and treatment, dated July 2, 2024, indicated that residents who were identified as at risk for the development of pressure injuries (skin impairment caused by pressure) were to have interventions in place to promote skin integrity. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 89, dated July 12, 2024, revealed that the resident was cognitively impaired and required assistance for daily care tasks, and had medical diagnoses that included stroke, coronary artery disease, and high blood pressure. The resident's current care plan indicated that she had left-sided weakness and required pressure-reducing support surfaces to prevent skin breakdown. Care plan interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed to provide tracheostomy care (care of a surgical incision in the neck that creates an opening into the windpipe) for one of 39 residents reviewed (Resident 127). Findings include: The facility's policy for tracheostomy care, dated July 2, 2024, indicated that tracheostomy care should be provided as per physician's orders and documented as completed in the electronic Medication Administration Record (eTAR) Treatment Page. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 127, dated May 28, 2024, revealed that the resident was cognitively intact, required limited assistance with daily care needs, and had diagnoses that included tracheostomy (surgical incision in the neck that creates an opening into the windpipe) and chronic respiratory failure (blood does not have enough oxygen and causes difficulty breathing). A care plan for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for two of five nurse aides reviewed (Nurse Aides 5, 6). Findings include: Review of nurse aide performance evaluation records revealed that Nurse Aide's 5 and 6 were each hired over one year ago, with a hire date of October 10, 2022. Neither of these nurse aides had performance evaluations completed in the past year. Interview with the Director of Nursing on August 1, 2024, at 1:55 p.m. confirmed that she was unable to find documentation to show that the above nurse aides had an annual performance evaluation completed in the past year. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
- Potential for harm · D2024-08-01 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending August 3, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending August 1, 2024, identified repeated deficiencies related to assessment coding, developing and revising residents' care plans, services provided meeting professional standards, and quality of care. The facility's plan of correction for a deficiency regarding assessment coding, cited during the survey ending August 3, 2023, revealed that audits of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$40,641 in federal fines across 1 penalty.
- $40,641 — penalty dated 2024-08-01
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 CARMELITE SISTERS FOR THE AGED & INFIRM — 9 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 | 4 of 5 | 2.8 | +1.2 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 3 of 5 | 3.8 | -0.8 vs chain |
| Quality measures | 5 of 5 | 3.9 | +1.1 vs chain |
The other 8 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DALE, STEVE | Individual | W-2 MANAGING EMPLOYEE | since 09/17/2018 |
| FERENCHAK, THERESA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 01/04/2010 |
| HIRNER, MARY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 01/04/2010 |
| ANDREWS, DAVID | Individual | CORPORATE DIRECTOR | since 02/01/2017 |
| BELL, MARY | Individual | CORPORATE DIRECTOR | since 02/01/2017 |
| HALEY, MARGARET | Individual | CORPORATE DIRECTOR | since 06/15/2015 |
| KARCHER, CYNTHIA | Individual | CORPORATE DIRECTOR | since 05/20/2014 |
| KARCHER, RICHARD | Individual | CORPORATE DIRECTOR | since 01/04/2010 |
| MACK, DIANE | Individual | CORPORATE DIRECTOR | since 01/04/2010 |
| MALOY, BARBARA | Individual | CORPORATE DIRECTOR | since 02/01/2017 |
| MURRAY, GERALD | Individual | CORPORATE DIRECTOR | since 01/04/2010 |
| OSINSKI, RONALD | Individual | CORPORATE DIRECTOR | since 04/16/2015 |
| RAWDON, PATRICIA | Individual | CORPORATE DIRECTOR | since 01/04/2010 |
| ROSS, PAULINE | Individual | CORPORATE DIRECTOR | since 02/01/2017 |
| SALY, ROBERT | Individual | CORPORATE DIRECTOR | since 11/25/2013 |
| STEVER, MATTHEW | Individual | CORPORATE DIRECTOR | since 05/20/2014 |
| THOMAS, ALAN | Individual | CORPORATE DIRECTOR | since 03/30/2016 |
CMS files one row per role, so the 19 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 395050. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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.