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Hollidaysburg Veterans Home

500 Municipal Dr, Hollidaysburg, PA 16648 · Government - State · 257 certified beds · (814) 696-5356 Medicaid only — no Medicare

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Flagged for abuse1 actual-harm citation2 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
601 Hawthorne Dr · (814) 942-1881 · Call to confirm hours
Pharmacy
Pharmacy0.5 mi
1201 Blair Street
Grocery
810 Church St · (814) 695-0717 · Call to confirm hours
Park
1407 Blair St · (814) 696-0877 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 held steady at 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.1%16.8%15.4%better
Long-stay residents who lose too much weight7.6%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.7%0.9%typical
Long-stay residents with a urinary tract infection1.3%1.5%2.0%better
Long-stay residents with depressive symptoms1.8%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.0%3.1%3.3%worse
Long-stay residents whose ability to walk worsened7.4%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.1%20.0%18.9%typical
Long-stay residents given the seasonal flu vaccine94.4%93.5%95.3%typical
Long-stay residents with pressure ulcers5.4%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control24.5%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.6%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication8.3%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine97.1%68.7%79.4%better
Long-stay hospitalizations per 1,000 resident days0.391.621.67better
Long-stay outpatient ER visits per 1,000 resident days1.751.181.80typical

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.23U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.

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

1.28
RN hours/ resident / day
1.40
LPN hours/ resident / day
2.44
Aide hours/ resident / day
5.13
Total nurse hours/ resident / day
0.84
RN hoursweekends
23.3%
Total nursing turnover
14.5%
RN turnover

How full it usually is: this home is certified for 257 beds and averages 187.3 residents a day — about 73% occupied, or roughly 70 beds typically open. It usually has some room. 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 5.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.28 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 4.62 hrs/resident/day on weekends vs 5.33 on weekdays — 13% thinner on weekends. RN hours go from 1.47 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-06-11)
11
at the previous standard inspection (2025-06-12)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

35 citations, most serious first. The 13 most serious are shown; the remaining 22 are one tap away and print in full.

  • Actual harm · Gcited before2026-05-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of six residents reviewed (Resident 3) resulting in a fall with fracture. This deficiency is being cited as past non-compliance.Findings include: A facility policy regarding resident falls dated January 1, 2026, that all unwitnessed falls or a known strike to the head or neck required the neurological evaluation process. A significant change minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 3, dated May 1, 2026, revealed that the resident was cognitively impaired, was occasionally incontinent of urine, and required substantial assistance with toileting hygiene. The resident's care plan, updated April 20, 2026, revealed that the resident had potential for falls and required his urinal to be kept at the bedside. A nursing note following a fall, dated April 14, 2026, indicated that Resident 3 stated he was trying to use his urinal but could not get his fancy pants off, referring to…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2026-02-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for assisting with Activities of Daily Living (ADL's) and preventing falls for one of seven residents reviewed (Resident 3), resulting in a fall and fracture for the resident. This deficiency was cited as Past Non-Compliance.Findings include: The facility's policy regarding resident abuse, dated January 5, 2026, revealed that the facility will provide protections for health, safety, welfare, and rights of each resident residing in the nursing home by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion, and any physical or chemical restraints not required to treat a resident's medical condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 6, 2026,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2026-02-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that protective devices to prevent injuries from falls were applied as care planned and ordered for one of seven residents reviewed (Resident R2) who fell and suffered a fracture and failed to ensure that the residents' environment remained free of accident hazards for one of seven residents reviewed (Resident 3), who fell and suffered a fracture. Findings include:The facility's policy regarding incidents and accidents, dated January 5, 2026, revealed that the facility's purpose was to maintain the residents' safety and prevention of serious injury to the extent possible and to ensure a consistent and effective approach to the management and review of the fall itself. If the resident was determined to be high risk for falls, the interdisciplinary team (IDT) would initiate, individualized preventative measures on an individual basis which may include, but not limited to hip savers (a padded under garment to protect the hip area).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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-06-11 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure 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, observations, and resident and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures. Findings include:The facility's policy regarding food temperatures, dated January 1, 2026, indicated that all hot foods were to be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F).Interview with a group of residents on June 10, 2026 at 2:00 p.m. revealed that the hot food is served warm or cold and that asking staff to reheat it in the microwave takes too much time. They stated that the residents that eat in their rooms are served first causing the food that sits in the dining room to cool down before the residents in the dining room are served. Interview with Resident 31 on June 8, 2026 at 12:14 p.m. revealed that the food is cold, the soup is always served cold, and that the plates are even cold. Interview with Resident 48 on June 8, 2026 at 12:19 p.m. revealed that the food is cold. She said that the food is…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Fcited before2026-06-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — 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 under sanitary conditions.Findings include:The facility's policy for food storage, dated January 1, 2026, revealed that all prepared items would be covered, labeled and dated clearly. Observations in the main kitchen on June 8, 2026, at 9:13 a.m. revealed that a stand up fan had a build up of black dust and debris on the cage and was blowing towards the food prep area; and at 9:33 a.m. in the walk-in freezer located in the basement, there were 11 birthday gobs that were not dated. Interviews with the Dietary Manager on June 8, 2026, at 9:13 a.m. and 9:33 a.m. confirmed that the dirty fan should not have been blowing towards the food prep area and needed cleaned, and the gobs should have been dated. 28 Pa. Code 211.6(f) Dietary Services.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-11 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 56 residents reviewed (Resident 5) who had a feeding tube.Findings include: A facility policy for feeding tubes, dated January 1, 2026, indicated that feeding tube use occurs based on current clinical standards of practice with the intent to maintain the resident's nutrition and hydration status within acceptable parameter and decrease the risk of complications from use. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 20, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and had a feeding tube. Physician's orders for Resident 5, dated March 27, 2026, included orders for the resident to receive Novasource (a tube feeding formula) at 250 milliliters/hour as needed if the resident ate less than 50% for breakfast, lunch and dinner. Review of Resident 5's meal intakes 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to administer a resident's continuous oxygen as ordered for one of 56 residents reviewed (Resident 174).Findings include:The facility's policy regarding oxygen therapy, dated January 1, 2026, indicated that supplemental oxygen therapy is provided and monitored for residents as per the provider's order, or in emergency situations, for the ease and comfort of respiratory effort and disease symptom management.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 174 dated June 4, 2026, indicated that the resident was cognitively intact, required supervision with daily care needs, received oxygen therapy, and had a diagnosis of chronic obstructive pulmonary disease (COPD- a disease that causes airflow blockage and breathing-related problems).Physician's orders for Resident 174, dated May 28, 2026, included an order for the resident to receive continuous oxygen at a flow…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the facility policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the appropriate instructions for administration for two of 56 residents reviewed (Resident 66, 83). Findings include: The facility's policy regarding medication administration and labeling, dated January 1, 2026, indicated that it is the purpose to provide guidance regarding medication administration to be in accordance with good nursing principles and practices and only by people legally authorized to do so. Labels for individual drug containers must include directions for use. Only the container in which a prescription drug or device is sold or dispensed to the ultimate consumer shall bear a label which shall be written in ink, typed or computer generated and shall contain full directions for the use of its contents. Manufacturer's directions for the use of Jardiance (used to manage diabetes) dated April 2026, revealed that Jardiance should not be split, broken or crushed, this may affect the medications absorption 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of established infection control guidelines, facility policy, 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 one of 56 residents reviewed (Resident 90).Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that 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…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-26 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of six residents reviewed (Resident 2). The facility's policy regarding changes in condition, dated January 1, 2026, indicated that when there was a change in the resident's condition, staff would notify the covering Registered Nurse who would then update the supervisor, physician, and family.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 29, 2026, revealed that the resident was cognitively intact, had diagnoses that included chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow, making it difficult to breath, and used a CPAP (a Continuous Positive Airway Pressure) machine to provide pressured oxygen through a mask to keep his airway open.A progress note for Resident 2, dated May 18, 2026, at 1:19 a.m. indicated that the CPAP machine was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide scheduled toileting following a fall for one of six residents reviewed (Residents 3).Findings include:The facility policy for urinary catheter care, dated January 8, 2026, indicated that changing indwelling catheters or drainage bags at routine, fixed intervals, was not recommended. Rather it was suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised.An email was sent on March 11, 2026 for nursing supervisors to discuss incontinent care with no double briefing- toileting and changing residents every two hours documentation needs to be in point of care (POC) with all care, staff cannot block chart at the beginning of their shift and then the resident falls and it appears via documentation that the resident hasn't been changed all shift. The blue tile for incontinent care in POC changes to white after the first entry, but they can continue to add in rounds…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect as the cause of a fracture for one of seven residents reviewed (Resident 2).Findings include:The facility's policy regarding falls, dated January 5, 2026, revealed that upon observation of a resident on the floor/lower level or witnessing a fall, if able, staff were stay with the resident and call for assistance. The Registered Nurse Supervisor was to be notified immediately. Staff were to document complete fall information, to include how the resident was found, environment around the resident, possible reason for fall, any applicable immediate interventions placed, any alteration in skin integrity, changes in prior known condition, and above notifications in the resident's electronic health record.The facility's policy regarding resident abuse/neglect, dated January 5, 2026, revealed that the facility would conduct a thorough investigation to determine facts specific to the case…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-12 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 59 residents reviewed (Resident 140). Findings include: Review of the facility's current dialysis policy, dated July 1, 2024, revealed that when the resident returns from dialysis the resident will be assessed by a registered nurse with a complete set of vital signs and the dialysis access permacath (a catheter used for dialysis access) or fistula (a surgically created access point for dialysis) would be assessed for bleeding every 15 minutes for two hours. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 140, dated April 25, 2025, indicated that the resident was cognitively impaired, had a diagnosis of kidney failure, and received dialysis. The current care plan revealed that Resident 140 goes to dialysis early in the morning on Tuesdays, Thursdays, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · Ecited before2025-06-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared under sanitary conditions. Findings include: Observations in the main kitchen on June 9, 2025, at 9:20 a.m. revealed that the large plastic flour container, the large plastic sugar container, and the large plastic thickening powder container, located in the preparation area, was still in the original paper containers of flour, sugar, and powder thickener while stored inside each of the plastic containers. Interview with Dietary Manager on June 9, 2025, at 9:20 a.m. revealed that she was not aware of any reason that the original paper containers should not be inside the large plastic containers. 28 Pa. Code 211.6(f) Dietary Services.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-12 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for three of 59 residents reviewed (Residents 53, 136, 171). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated March 26, 2025, indicated that the resident was cognitively intact, was independent for care, and received enteral feeding. Physician's orders, dated April 9, 2025, included an order for the resident to receive Isosource 1.5 (a tube feeding formula) at 250 milliters (ml) per hour over one hour three times a day, provide 85 ml flush before and after feeding, and document the amount of feed and flush administered. A review of Resident 53's Medication Administration Record (MAR), dated April, May, June 2025, indicated that staff were not correctly documenting the amount of feeds and flushes. On April 10, 2025, at 9:00 a.m. 100 ml was documented, and there was do documented evidence if the resident received pre…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 observations and staff interviews, it was determined that the facility failed to maintain confidentiality of residents' personal health information during medication administration for one of 59 residents reviewed (Resident 78). Findings include: The facility policy regarding privacy of health information, dated July, 1 2024, indicated that the facility was to protect the confidentiality of a resident's health information. Observations of the [NAME] building's North Hall on June 11, 2025, at 12:21 p.m. revealed a medication cart at the end of the hallway, the computer on top of the medication cart was on, and Resident 78's personal information was visible on the screen. Interview with Licensed Practical Nurse 1 on June 11, 2025, at 12:27 p.m. confirmed that she should have covered Resident 78's personal information on the computer screen when leaving the medication cart. Interview with the Director of Nursing on June 11, 2025, at 1:41 p.m. confirmed that the computer…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one 59 residents reviewed (Resident 139). Findings include: The facility's abuse policy, dated July 1, 2024, indicated that each resident had the right to be free from abuse, neglect and misappropriation of resident property. Abuse is defined as, the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being, which includes verbal, sexual, physical and mental abuse. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 139, dated January 7, 2025, indicated that the resident was moderately cognitively impaired, required moderate assistance from staff with…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 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 one of 59 residents reviewed (Resident 169). Findings include: A facility policy regarding interdisciplinary care plans, dated July 1, 2024, indicated that each resident has an individualized interdisciplinary care plan. Proper documentation was required in the care plan for discontinued or added interventions, changes in problems, goals, and interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 169, dated February 4, 2025, revealed that the resident was understood, could understand others, was moderately cognitively impaired, required supervision for showering and bathing, was independent with all other care needs, and had diagnoses that included heart failure and Alzheimer's disease. Nursing notes, dated February 16, 2025, indicated that Resident 169 fell at his daughter's home, was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of 59 residents reviewed (Resident 140). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 140, dated April 25, 2025, indicated that the resident was cognitively impaired and had diagnoses that included kidney failure and received dialysis. A care plan for nutritional status, dated January 26, 2024, revealed that the resident goes to dialysis at 6:00 a.m. on Tuesdays, Thursdays, and Saturdays. Physician's orders for Resident 140, dated January 26, 2024, included an order for the resident to receive at 9:00 a.m. 1 milligram (mg) of bumetanide (a medication to treat edema), 25 microgram (mcg) of vitamin D3, 2.5 mg of Eliquis (a blood thinner), one 50 mcg spray per nostril of Flonase (a medication to treat allergies), 0.5 mg of lorazepam (a medication to treat anxiety), 10 mg of midodrine, 75 mg of Plavix (a medication to help…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that fall interventions were in place for one of 59 residents reviewed (Resident 9) who had a history of a fall from his bed, and failed to lock the wheels on a hoyer lift during use per manufacturer's instructions for one of 59 residents reviewed (Resident 186). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated March 25, 2025, revealed that the resident was cognitively intact, was dependent for most daily care needs including bed mobility, and had a diagnoses that included hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury) of the left side following a stroke. The current fall care plan for Resident 9 revealed that the resident was at risk for falls. Interventions for Resident 9 included the use of a long positioning wedge to the left side at all times when in bed. Physician's orders 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 59 residents reviewed (Resident 53). Findings include: The facility's policy regarding medication administration, dated July 1, 2025, indicated that staff were to document that medication was given on the appropriate line of the resident's Medication Administration Record (MAR). Physician's orders for Resident 53, dated April 9, 2025, included an order for the resident to receive 10 milligrams (mg) of Oxycontin (a controlled narcotic pain medication) every four hours as needed. Resident 53's controlled drug records for May 2025 revealed that a 10 mg dose of Oxycontin was signed-out for administration once on May 1, 2025, at 12:42 p.m.; May 13, 2025, at 6:00 p.m.; May 24, 2025 at 5:22 p.m.; and May 27, 2025 at 10:20 p.m. However, the resident's clinical record, including the MAR, contained no documented evidence that the Oxycontin was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — 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 ensure that medications were properly secured in the medication cart. Findings include: The facility's policy regarding medication storage, dated July 2, 2025, indicated that the nurse was to ensure the medication cart was securely locked at all times when out of the nurse's view. Observations on June 11, 2025, at 12:21 p.m. revealed that a medication cart in the hallway was unlocked and unattended by Licensed Practical Nurse 1 when she went to the nurse's station. Interview with Licensed Practical Nurse 1 on June 11, 2025, at 12:27 p.m. confirmed that her medication cart should have been locked when unattended. Interview with the Director of Nursing on June 11, 2025, at 2:06 p.m. confirmed that the medication cart should have been locked when unattended by Licensed Practical Nurse 1. 28 Pa. Code 211.9(a)(1)(k) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set 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 plan of corrections for an annual survey ending July 18, 2024, 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 June 12, 2025, identified repeated deficiencies related to a failure to protect the residents from abuse/neglect, failure to have accountability for controlled medications, failure to ensure that food was stored and served properly, and failure to ensure that medical records were complete and accurate. The facility's plan of correction for a deficiency regarding abuse/neglect, cited during 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    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 accommodate a resident's preference for a shower for one of 54 residents reviewed (Resident 57). Findings include: A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated June 19, 2024, revealed that the resident was understood, could understand others, and had diagnoses which included a stroke with hemiplegia (paralysis on one side of the body) and Chronic Obstructive Pulmonary Disease (COPD - a common lung disease causing restricted airflow and breathing problems). A care plan for the resident, dated October 18, 2022, revealed that the resident had a potential for Activities of Daily Living (ADL) self-care deficit related to the presence of mobility deficits to left upper extremity secondary to a stroke. Staff were to shower the resident two times per week on the 3:00 p.m. to 11:00 p.m. shift after supper on Mondays and Thursdays. Physician's orders for Resident 57, dated October…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-18 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 a review of the Pennsylvania Nurse Practice Act, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse provided care and services according to accepted standards of clinical practice for three of 54 residents reviewed (Residents 21, 100, 124) and the facility failed to ensure that physician's orders were clarified for one of 54 residents reviewed (Resident 118). 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. A facility policy regarding medication administration, dated July 1, 2024, indicated that after clearly identifying the resident via the name band and 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for two of 54 residents reviewed (Residents 118, 152). Findings include: The facility policy for bowel monitoring, dated July 1, 2024, indicated that if a resident has not had a bowel movement within the last nine shifts, an oral administration of a bowel stimulant should be administered. If the resident does not have a medium or large bowel movement within the next shift, a rectal administration of a bowel stimulant should be administered. If the resident does not have a medium or large bowel movement within the next shift after the rectal bowel stimulant, an enema should be administered. If the resident does not have a medium or large bowel movement after one hour of receiving the enema, an abdominal assessment should be completed, and the physician should be notified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 118, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-18 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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 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 54 residents reviewed (Residents 160). Findings include: A facility policy for medication administration, dated July 1, 2024, indicated that when administering a narcotic, the medication nurse will compare the amount of narcotic recorded on the narcotic administration and disposition record (a form that accounts for each tablet/pill/dose of a controlled drug) making sure amounts are correct in addition to clicking complete on the electronic Medication Administration Record (eMAR) following administration. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 160, dated May 8, 2024, indicated that the resident was cognitively impaired, required partial to moderate assistance for her daily care needs, and had diagnoses that included breast cancer. Physician's orders for Resident 160,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared under sanitary conditions. Findings include: The facility's policies regarding food preparation and service, as well as sanitization, dated July 1, 2024, indicated that all refrigeration and storage areas must be well lit, clean and free from overhead leakage and dampness. All food items must be stored in properly-covered containers, labeled, dated upon opening, and stored at least six inches off the floor on acceptable shelving. Prepackaged foods will be discarded by dietary services on the expiration date. Food brought into residents by family will be labeled by nursing with resident's name and date and will be discarded by dietary services on the expiration date. Observations in the main kitchen on July 15, 2024, at 9:08 a.m. revealed that the refrigerator in had an opened and undated container of beef broth that was half full and an area of standing…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 54 residents reviewed who were receiving hospice services (Resident 160). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 160, dated May 8, 2024, indicated that the resident was cognitively impaired, required partial to moderate assistance for her daily care needs, had diagnoses that included breast cancer, and was receiving hospice services. The care plan for Resident 160, dated May 6, 2024, included that the resident was receiving hospice services with UPMC family hospice and hospice staff were to give written and oral reports to the facility after each visit with the resident. A nurse's note for Resident 160, dated May 3, 2024, at 8:39 p.m., included that the resident returned from the hospital at 6:40 p.m. and the hospice nurse was at 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working 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 ensure that the main kitchen walk-in freezer was maintained in good condition. Findings include: Observations in the walk-in freezer in the main kitchen on July 15, 2024, at 9:12 a.m. revealed that there was a large accumulation of ice on the fans. Interview with the Dietary Director on July 15, 2024, at 9:12 a.m. confirmed that there was a large accumulation of ice and that it should not be built up on the fans. 28 Pa. Code 207.2 (a) Administrator's Responsibility.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance with incontinent care was provided in a manner to maintain dignity for one of 54 residents reviewed (Resident 106). Findings include: The facility's policy regarding resident rights, dignity, and respect, dated July 1, 2024, revealed that the staff, vendors, contractors, agencies, and anyone engaging in work for the facility shall display respect for the residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings. All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input. A Significant…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to provide assistance with toileting for one of 54 residents reviewed (Resident 106), resulting in the resident being incontinent of bladder. Findings include: The facility's policy regarding abuse prevention, dated July 1, 2024, indicated that it is the process of the facility to provide protections for the health, safety, welfare, and rights of each resident residing in the facility by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion, and any physical or chemical restraints to treat a resident's medical condition. The facility's policy regarding resident rights, dignity, and respect, dated July 1, 2024, revealed that the staff, vendors, contractors, agencies, and anyone engaging in work for the facility shall display respect for the residents when speaking with, caring…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for one of 54 residents reviewed (Resident 118). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 118, dated June 12, 2024, indicated that the resident was cognitively intact, was independent with personal hygiene needs and eating, and had diagnoses that included Waldenstrom macroglobulinemia (an uncommon blood cell cancer). Physician's orders for Resident 118, dated December 11, 2023, included an order for the resident to have built-up utensils for meals. A care plan for Resident 118, dated December 12, 2023, indicated that the resident had the potential for altered nutrition and that built-up utensils were to be used for meals. Observations of Resident 118 during the lunch meal on July 16, 2024, at 1:03 p.m. revealed that the resident was in his room eating his meal…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 54 residents reviewed (Resident 154). Findings include: The facility's policy for Medication Administration, dated July 1, 2024, indicated that after administering the narcotic, the medication nurse will record the date the narcotic was administered, sign their name, record the amount of the narcotic administered, record the time the narcotic was administered, and the remaining balance of the narcotic on the Narcotic Administration and Disposition Record. The specific time the narcotic was given will be reflected on the eMAR when the licensed nurse clicks Complete indicating that the narcotic was administered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 154, dated April 16, 2024, revealed that she was understood and understood others, was cognitively impaired, and received pain…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of established infection control guidelines, facility policy, 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 54 residents reviewed (Residents 87, 128). Findings include: Facility policy for hand hygiene, dated July 1, 2024, indicated that hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. Hand hygiene must be performed before donning (put on) and after removing personal protective equipment, including gloves. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 87, dated July 3, 2024, revealed that the resident was cognitively intact, was dependent on staff for care needs, was always incontinent 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in PA

Paying with Medicaid

CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.

Typical monthly cost in Pennsylvania
$11,954/mo
Nursing home (semi-private)
$13,688/mo
Nursing home (private)
$6,480/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 39A437. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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