Presbyterian Homes-Presby
220 Newry Street, Hollidaysburg, PA 16648 · Non profit - Corporation · 67 certified beds · (814) 693-4000 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)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
- inspectors recorded 3 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 (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $24,759 in federal fines (most recent 2025-02-05)
- its payroll-based staffing score sits well above its independent inspection score
- about 17% of its spending goes to commonly-owned related companies
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 3 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 | 12.2% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.6% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 10.8% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.1% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.9% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 39.1% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.3% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.2% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.6% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.0% | 68.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 27.7% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.3% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.73 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.98 | 1.18 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
39.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 39.8%CMS range 31.5–48.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.1–14.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 61.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 61.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 77.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 4.0–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 67 beds and averages 64.8 residents a day — about 97% occupied, or roughly 2 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.75 on weekdays — 12% thinner on weekends. RN hours go from 1.06 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
36 citations, most serious first. The 13 most serious are shown; the remaining 23 are one tap away and print in full.
- Actual harm · Gcited before2025-02-05 · 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 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 devices to prevent accidents or injury were in place as care planned for one of six residents reviewed (Resident 2) who was at risk for falls, resulting in a fall with multiple fractures. This deficiency was cited as past non-compliance. Findings include: The facility's fall management policy, dated January 30, 2025, indicated that the facility would provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. The facility would ensure the resident environment remained as free of accident hazards as possible. When a resident sustained a fall, the assessment process would include an investigation using the Fall Investigation analysis sheet. The fall investigation would be used to evaluate probable causal factors, which may include environmental factors, resident medication condition, resident behavioral manifestations, 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.
- Actual harm · Gcited before2024-07-22 · 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, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow the facility's policy for obtaining temperatures of hot liquids for one of two residents reviewed (Resident 1), resulting in the resident spilling her coffee and causing a burn. This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding resident abuse, dated February 8, 2024, revealed that each resident is provided a safe environment where they are not subjected to mental, physical, verbal, and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property. Neglect is defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility's policy regarding reheating of hot food/beverages, 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.
- Actual harm · Gcited before2024-07-22 · 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 review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by serving hot coffee in a cup without a lid to one of two residents (Resident 1) without first obtaining a temperature to ensure that it was not greater than 140 degrees Fahrenheit, resulting in third degree burns when it was spilled on the resident. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding reheating of hot food/beverages, dated February 8, 2024, revealed that when serving hot beverages the maximum temperature should not be greater than 140 degrees Fahrenheit (F). An accurate temperature of all menu items, including hot beverages, are to be taken and recorded on the food temperature log. The facility's policy regarding food temperature logs, dated February 8, 2024, revealed that food temperatures of cold and hot items will be recorded on all menu items for meal service. All employees are responsible for notifying…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-20 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a 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 five of 31 residents reviewed (Residents 6, 7, 28, 55, 61). Findings include:The Long-Term Care Facility RAI User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs), dated October 2024, revealed that Section N was to be coded for medications received in the last seven days. Section N0415C was to be coded if the resident received an antidepressant medication in the previous seven days, Section N0415F1 was to be coded if the resident received an antibiotic medication in the previous seven days, and Section N0415K1 was to be coded if the resident received an anticonvulsant medication in the previous seven days. Physician's orders for Resident 6, dated August 29, 2025, included an order for the resident to receive 300 mg of Gabapentin (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 · Ecited before2025-11-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in two of two kitchenettes reviewed (first and second floor).Findings include: The facility policy regarding food storage, dated January 30, 2025, revealed that food should be stored in such a manner as to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption. Observations in the kitchen's walk in dry storage room on September 29, 2025, at 9:37 a.m. revealed that there a bag of decorative sprinkles (approximately 10 pounds) that was open to the air, and one pound of [NAME] powder that expired on April 18, 2022. Observations in the second floor kitchenette's refrigerator/freezer on October 1, 2025, at 8:35 a.m. revealed a head of lettuce that was open to the air in the refrigerator, and two bags of frozen hot dogs (approximately 40) and a bag of six frozen hamburgers that were open…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-20 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for six of nine residents observed (Residents 10, 15, 26 34, 53, 59). Findings include:The facility's policies regarding oral medication administration and hand hygiene, dated January 30, 2025, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications, and after glove removal.Observations during the medication pass on the 200 hall on October 1, 2024, at 7:40 a.m. revealed that Licensed Practical Nurse (LPN) 6 prepared Resident 53's medications and administered them. Without sanitizing his hands he prepared and administered Resident 26's medications, without sanitizing his hands LPN 6 donned gloves, prepared and administered Resident 59's medications, doffed his gloves and without sanitizing his hands he prepared and administered Resident 34's medications, without sanitizing his hands he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-20 · 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 31 residents reviewed (Resident 55). Findings include:The facility's policy regarding Abuse, Neglect, and Exploitation, dated January 31, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse, and that residents would be protected from mistreatment, 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 55 dated July 13, 2025, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia.Resident 55's care plan, dated June 1, 2025, indicated that the resident had dementia, as well as anxiety and agitation.The facility's investigation documents for Resident 55, dated August 15, 2025,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-20 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer to the hospital, for three of 31 residents reviewed (Residents 4, 8, 75), Findings include:The facility policy for Admission, Transfer and Discharge Notification, dated January 30, 2025, indicated that upon transfer to the hospital the resident and resident representative will be notified in writing, and the ombudsman will be notified.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 14, 2025, indicated that the resident was moderately cognitively impaired, usually understood and usually understands, required assistance from staff for her daily care needs and had diagnoses that included, cerebral infarct (stroke).Review of Resident 4's clinical record indicated that on July 4, 2025 at 1:23 p.m. 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 before2025-11-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that bowel protocols were followed as ordered by the physician for one of 31 residents reviewed (Resident 61).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated September 9, 2025, revealed that the resident was cognitively intact and was frequently incontinent of bowel movements. Physician's orders for Resident 61, dated April 28, 2025, included orders for the resident to receive 30 milliliters of Milk of Magnesia as needed for no bowel movements for three days, give on day 4 of no bowel movement; a 10 milligram dulcolax suppository rectally as needed for no bowel movement for four days, give on day five of no bowel movement; and a Fleets enema to be given rectally as needed for no bowel movement for five days, give on day six of no bowel movement. Review of Resident 61's bowel records for August and September 2025 revealed that there was no documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-20 · tag F0849 — isolatedArrange 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 review of hospice contracts and clinical records, as well as 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 five hospice residents reviewed (Resident 10). Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services) indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). Physician's orders for Resident 10, dated April 25, 2025, revealed that the resident was to receive hospice services. As of September 30, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice benefit of elections form from the hospice provider.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-10 · 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident representative was notified timely about a change in condition for one of three residents reviewed (Resident 2).Findings include:The facility's policy regarding changes in condition, dated January 30, 2025, indicated that the facility would provide timely notification to families, resident representatives, powers of attorney, physicians, and staff of changes in resident medical conditions consistent with regulation and resident choice.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 5, 2025, revealed that the resident was severely cognitively impaired, usually understood, could sometimes understand, required assistance with care needs, and had diagnoses that included dementia.A grievance filed by the resident representative on July 24, 2025, revealed that Resident 2's glasses were missing. The glasses were replaced by 360 care. The investigation…
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 before2025-02-05 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for bowel protocols/medications were followed for three of six residents reviewed (Residents 1, 2, 3). Findings include: The facility's policy regarding bowel management, dated January 30, 2025, indicated that the facility would follow the facility-specific bowel protocol or physican orders. A quarterly MDS assessment for Resident 1, dated November 9, 2025, revealed that the resident was severely cognitively impaired, was continent of bowel, and had diagnoses that included kidney failure, anemia, and dementia. Physician's orders for Resident 1, dated July 10, 2024, included orders for the resident to receive 30 mL of Milk of Magnesia as needed for constipation if no bowel movement on day four, a 10 mg Dulcolax suppository as needed if the resident did not have a bowel movement on day five day, and a Fleets enema on day six with no bowel movement if the Dulcolax suppository was not effective. Review of Resident 1's bowel records…
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 before2025-02-05 · 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 clinical records and 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 six residents reviewed (Resident 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 4, 2024, indicated that the resident was cognitively intact and had a history of falls. The care plan, dated December 22, 2024, through February 1, 2025, for Resident 3 revealed that the resident was non-compliant and at risk for falling and had the following interventions in place: provide environment free of clutter, keep call bell light in reach at all times, keep personal items and frequently used items within reach, kid cushion to the night stand, gripper socks on while in bed, reminder signs to ring for assistance, non-skid strips to the right side of the bed, bed height marked on the wall for bed height, anti-roll back devices to wheelchair, offer to lie down after…
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 23 citations
- Potential for harm · D2025-02-05 · tag F0810 — isolatedProvide 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 clinical record reviews, 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 six residents reviewed (Resident 1). Findings include: The facility's policy regarding adaptive feeding devices, dated January 30, 2025, indicated that the facility would provide the resident with the most independent and safe way of eating. A quarterly Minimum Data Set (MDS) assessment for Resident 1, dated November 9, 2024, indicated that the resident was severely cognitively impaired and was independent with eating after set up. The resident's care plan, dated November 27, 2024, and speech therapy clinical notes, dated December 21, 2024, indicated that her food was to be provided in bowls and given to her one at a time. Observations of Resident 1 during the lunch meal on February 5, 2025, at 11:50 p.m. revealed that the resident was at a dining room table eating her meal, and her pork, mashed potatoes and sauerkraut were served on a plate. The resident's 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.
- Potential for harm · Dcited before2024-11-05 · 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 and clinical records, as well as staff interviews, it was determined that the facility failed to transcribe physician's orders related to medication changes for one of seven residents reviewed (Resident 1). 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 quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 30, 2024, indicated that the resident was cognitively impaired, required partial/moderate assist for transfers, and had a diagnosis that included dementia. Review of clinical records for Resident 1 revealed diagnoses that included a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 a review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of 23 residents reviewed (Resident 9). Findings include: The facility's policy regarding catheter care, dated February 8, 2024, indicated that catheter care will be performed with morning and evening care and as needed after incontinence or bowel movements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated July 10, 2024, revealed that the resident was cognitively impaired and required extensive assistance from staff for all care. A care plan for Resident 9, dated July 6, 2024, revealed that the resident had an indwelling foley 16 French, 10 cc balloon catheter (a thin flexible tube inserted into the bladder to drain urine). Observations of Resident 9 on September 4, 2024, at 11:35 a.m. revealed that the resident was in bed and the indwelling foley that was in place was a 16 French, 10 cc…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was discarded after it was outdated. Findings include: The facility's policy regarding labeling and dating food, dated February 8, 2024, revealed that food was to be discarded past the use-by or expiration date. Observations in the kitchen on September 3, 2024, at 9:15 a.m. revealed three half-gallons of half and half creamer that were expired. Observations in the cooler revealed two large containers of expired sour cream and two large containers of expired ricotta cheese. Observations in the dry storage room revealed two cartons of expired apple juice and five cartons of apple juice with no manufacturer's expiration date. Interview with the Dietary Manager on September 3, 2024, at 9:43 a.m. confirmed that all items should be thrown out when they expire and should not be used. Observations in the first floor kitchenette on September 5, 2024, at 2:12 p.m. revealed a large container of cottage cheese, opened and in use, that had expired on September…
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 before2024-09-05 · 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 23 residents reviewed (Residents 4, 49). Findings include: The facility's policy regarding care plans, dated February 8, 2024, indicated that the facility would evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by their Mission Statement as well as State and Federal guidelines. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 21, 2024, revealed that she was cognitively intact, was dependent on staff for activities of daily living, and had a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall). A care plan for Resident 4, dated June 19, 2024, indicated that the resident was to have her colostomy emptied when the bag is one-third…
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 before2024-09-05 · 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for the care and to maintain the patency of an intravenous access device for one of 23 residents reviewed (Resident 4). Findings include: The facility's policy for intravenous device care, dated February 8, 2024, indicated that orders for flushing and care of intravenous device will be obtained to maintain device and prevent obstruction. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 21, 2024, revealed that the resident was cognitively intact and required assistance from staff for his daily care needs. A nurse's note for Resident 4, dated July 24, 2024, at 7:53 p.m., revealed that the right port flush was completed and had a good blood return. The next port flush will be in three months. Observations on September 3, 2024, at 11:48 a.m. revealed that Resident 4 had a Mediport (intravenous access device that allows 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 before2024-09-05 · 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 policy and 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 23 residents reviewed (Resident 38). Findings include: A facility policy for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), dated February 8, 2024, revealed that if a resident had a blood glucose (sugar) reading of 350 mg/dL or greater, the physician would be notified. If the blood glucose was less than 70 mg/dL and the resident was able to swallow without symptoms, offer three to four glucose tablets or four to five saltine crackers and may repeat in 15 minutes if glucose remains low. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated June 21, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, and received insulin (medication that lowers blood sugar levels). Physician's orders for Resident 38, dated February 2, 2023, included an order for 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 · D2024-09-05 · 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen therapy was provided as ordered for one of 23 residents reviewed (Resident 38). Findings include: The facility's policy regarding oxygen administration, dated February 8, 2024, indicated that a physician's order for oxygen was to include the liter flow and method of administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated June 8, 2024, revealed that the resident was cognitively intact, required substantial assistance with care needs, used supplemental oxygen, and had diagnoses that included respiratory failure. Physician's orders for Resident 38, dated August 31, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 3 liters per minute via nasal canula (tubes that deliver oxygen into the nostrils) for hypoxia (low levels of oxygen in body tissues). Observations of Resident 38 in her room on September…
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 before2024-09-05 · 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 23 residents reviewed (Resident 57). Findings include: The facility's policy regarding destroying medications, dated February 8, 2024, indicated that medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations. Physician's orders for Resident 57, dated July 1, 2024, included an order for the resident to receive 5 milligrams (mg) (0.25 milliliters) of morphine sulfate (a controlled narcotic pain medication) orally every 2 hours for pain, and 5 mg of Oxycodone (a controlled narcotic pain medication) orally every 6 hours for pain. A discharge summary for Resident 57, dated July 4, 2024, revealed that the resident ceased to breathe on that date; however, there was no documented…
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 · D2024-09-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened in one of eight medication carts reviewed (split cart), and failed to ensure the narcotic box was permanently affixed inside the refrigerator. Findings include: The facility's policy regarding the storage of medications dated February 8, 2024, revealed that schedule (II-V) medications (medications with a greater potential to be abused) are to be stored in a permanently affixed and double locked compartment separate from all other medications. Observations in the 500 hall medication room refrigerator on September 4, 2024, at 9:40 a.m. revealed a clear, unlocked box containing an unopened 30 milliliter (ml) bottle of lorazepam 2 mg/ml (a schedule IV medication for anxiety). The box was secured to the shelf; however, the shelf was able to be removed. Interview with Licensed Practical Nurse 3 on September 4, 2024, at 9:43 a.m. confirmed that the narcotic box should have been locked and permanently affixed to the inside…
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 before2024-09-05 · 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 plan of corrections for an annual survey ending November 1, 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 September 5, 2024, identified repeated deficiencies related to a failure to revise care plans, failure to provide quality care, failure to have accountability for controlled medications, and failure to ensure that food was stored and served properly. The facility's plan of correction for a deficiency regarding revision of care plans, cited during the survey ending November 1, 2023, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-26 · 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of three residents reviewed (Resident 3). Findings include: The facility's policy regarding care planning, dated February 8, 2024, indicated that the facility will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by their Mission Statement as well as State and Federal guidelines. The overall care plan should be oriented towards involving the resident, the resident's family, and other resident representatives as appropriate. The facility's policy regarding change in medical condition, dated February 8, 2024, indicated that the facility must consult with a competent resident and notify the physician, appropriate facility staff, responsible party or designated person if applicable, significant other, and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-01 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity by feeding residents while standing for three of 26 residents reviewed (Residents 7, 32, 40). Findings include: The facility's policy regarding assisting resident meals, dated January 26, 2023, revealed that the residents may require different levels of assistance with meals based on their cognitive and/or physical needs. A basic guideline for assisting residents with meals included to sit at eye level with the residents. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated September 20, 2023, revealed that the resident was rarely/never understood, could rarely/never understand, required extensive assistance from staff for her daily care tasks including with eating, and had diagnoses that included Alzheimer's. A care plan, dated April 12, 2023, 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 · Ecited before2023-11-01 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding obtaining laboratory samples were followed for one of 26 residents reviewed (Resident 25) resulting in a delay of treatment. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated August 12, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, and had a urinary catheter (a tube inserted directly into her bladder). Physician's orders for Resident 25, dated September 4, 2023, included an order for the resident have a urine sample obtained and tested for an infection. Nursing note for Resident 25, dated September 5, 2023, revealed that a urine sample was obtained and sent to the lab. A nursing note, dated September 6, 2023, revealed that the urine sample obtained from Resident 25 was never picked up by the lab courier, so a new sample was obtained on that date. A nursing note, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-01 · tag F0694 — patternProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 central venous catheters were flushed per facility policy for one of 26 residents reviewed (Resident 47). Findings include: The facility's policy regarding flushing central venous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated January 26, 2023, indicated that the catheter was to be flushed before and after it was used to administer medication. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated September 20, 2023, revealed that the resident was cognitively intact, needed limited assistance for daily care needs, and had a diabetic foot ulcer (a wound to the foot due to a complication of diabetes (a disease caused by high blood sugar levels). Physician's orders for Resident 47, dated September 15, 2023, included an order for the resident's peripherally-inserted central catheter (PICC - a type…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-01 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical records reviews and staff interviews, it was determined that the facility failed to obtain the correct medication for one of 26 residents reviewed (Resident 25). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated August 12, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, and had a urinary catheter (a tube inserted directly into her bladder). Physician's order, dated February 16, 2022, included an order for the resident to receive AZO Cranberry (supplement used to reduce the risk of urinary tract infections), one tablet everyday. A nursing note for Resident 25, dated October 14, 2023, revealed that nursing staff noticed that the resident's urine was orange. When the nurse reviewed the resident's medications she noticed that the AZO Cranberry was not the correct medication. The resident was receiving AZO Cranberry with Pyridium (used to treat painful urination and turns the urine orange)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-01 · 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 observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at an acceptable temperature. Findings include: An interview with Resident 1 on October 30, 2023, at 11:54 a.m. revealed that the food tasted awful, was cold, and that he did not like it. An interview with Resident 37 on October 30, 2023, at 12:50 p.m. revealed that the chicken was hard and the food was served cold. Observations in the kitchen on October 31, 2023, at 12:21 p.m. during the lunch meal service revealed that a test tray left the kitchen and arrived on the nursing unit at 12:21 p.m. The lunch meal on October 31, 2023, consisted of country fried steak, mashed potatoes, peas with mushrooms, Swedish meatballs, and an ambrosia salad. Trays were passed to the residents in their rooms and the last resident was served and eating at 12:23 p.m. The test tray on October 31, 2023, at 12:23 p.m. revealed that the coffee was 65 degrees Fahrenheit (F) and cold to taste, the mashed potatoes were 106 degrees F and cold to taste, 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 · Ecited before2023-11-01 · 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 facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure that dietary staff wore hair coverings that completely covered their hair during food handling. Findings include: The facility's dietary policy regarding personal hygiene, dated January 26, 2023, revealed that staff were to wear a hat or hairnet and wear hair away from face. Observations in the kitchenette on the first floor on October 30, 2023, at 9:05 a.m. revealed dietary staff preparing meal trays for delivery to the units for the residents' breakfast. Breakfast was served from 7:30 a.m. to 9:30 a.m. The dietary aide was observed with approximately two to three inches of hair falling onto her forehead, not contained within her hairnet. Interview with the Dietary Director on October 30, 2023, at 9:25 a.m. confirmed that the dietary aide did not have all her hair covered with a restraint and that she should have. 28 Pa. Code 211.6(f) Dietary services.
- Potential for harm · D2023-11-01 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding serving food at a palatable and appropriate temperature. Findings include: The facility's policy regarding grievances, dated January 26, 2023, revealed that resolution of the grievance was desired within three to five working days from the date the concern was filed. Resident council meeting minutes, dated July 2023, indicated that the residents were frustrated with receiving melted ice cream on their meal trays. Resident council meeting minutes, dated August 2023, indicated that the food had been served cold and undercooked. A meeting with a group of residents on October 30, 2023, at 1:30 p.m. revealed that the residents were receiving food that was cold, unappetizing and unpalatable. A lunch tray on October 31, 2023, at 12:23 p.m. revealed that the coffee was 65 degrees Fahrenheit (F) and tasted cold, the mashed potatoes were 106 degrees F and tasted cold, the ground beef was 115 degrees F and tasted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-01 · 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 residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 26 residents reviewed (Residents 32, 47). 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 if the resident received hospice (end-of-life) services during the assessment period, then Section O0100K2 was to be checked. Physician's orders for Resident 32, dated June 1, 2023, included an order for the resident to receive hospice services. A care plan for Resident 32, dated September 6, 2023, revealed that the resident had chosen to receive Hospice services. A nursing note for Resident 32, dated June 5, 2023, revealed that the resident was admitted to Hospice services on June 3, 2023, with a diagnosis of Alzheimer's and dementia. A quarterly MDS assessment for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-01 · 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included specific and individualized interventions for two of 26 residents reviewed (Residents 14, 52). Findings include: The facility's care plan policy, dated January 26, 2023, indicated that each resident's care plan was to be reviewed, updated and/or revised based on changing goals, preferences, and needs of the resident, in order to promote their highest level of functioning. The plan of care should meet the resident's medical, nursing, mental and psychosocial needs. A comprehensive MDS assessment for Resident 14, dated August 17, 2023, indicated that the resident was severely cognitively impaired, required extensive assistance for all care needs, and was not ambulatory. A diagnosis record for Resident 14, dated August 14, 2023, included anxiety, atrial fibrillation (irregular heart rhythm), and depression. Physician's orders for Resident 14, dated September…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-01 · 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 clinical records and interviews with staff, it was determined that the facility failed to ensure that a resident's care plan was updated for three of 26 residents reviewed (Resident 37) who refused care and who had anticoagulant medication discontinued (Residents 25, 26) . Findings: The facility policy for care planning, dated January 26, 2023, indicated that resident care plans are to be updated as needed and should include person-centered care needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated August 12, 2023, indicated that the resident was cognitively impaired and that she required extensive assistance from staff for daily care needs. Physician's order's for Resident 25, dated January 19, 2022, included an order for the resident to receive 5 milligrams (mg) Eliquis (blood thinner) twice daily until it was discontinued on October 7, 2023. Resident 25's care plan, dated August 9, 2023, revealed that the resident was medicated with a blood thinner for history of a deep vein thrombosis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-01 · 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 correction for a State Survey and Certification (Department of Health) survey ending December 14, 2022, as well as a complaint survey ending July 28, 2023, revealed that the facility developed plans of correction that included development and implementation of care plans, quality of care, palatable food, and food procurement/storage/preperation under sanitary conditions. The results of the current survey, ending November 1, 2023, identified repeated deficiencies related to development and implementation of care plans, quality of care, palatable food, and food procurement/storage/preperation under sanitary conditions. The facility's plan of correction for a deficiency…
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
$24,759 in federal fines across 2 penalties.
- $15,935 — penalty dated 2025-02-05
- $8,824 — penalty dated 2024-07-22
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 PRESBYTERIAN SENIOR LIVING — 11 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 | 3.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 4 of 5 | 3.5 | +0.5 vs chain |
The other 10 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PHI | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2025 |
| PRESBYTERIAN HOMES IN THE PRESBYTERY OF HUNTINGDON | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2025 |
| BIRDSALL, JAMES | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| CHOTTINER, LAWRENCE | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| DAVIS, DANNY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2025 |
| DENISON, BARBARA | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| DERR, SCOTT | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| ELLIOTT, BRENDA | Individual | CORPORATE DIRECTOR | — | since 01/01/2022 |
| GOLDSTEIN, TERRY | Individual | CORPORATE DIRECTOR | — | since 01/01/2018 |
| HERSHEY, KATHERINE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2025 |
| KINARD, JOSEPH | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| MCALISTER, DYAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2025 |
| REIMANN, SUSAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2016 |
| RHODES, CHERYL | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| SEIBERT, JOSEPH | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| SHROPSHIRE, JENNIFER | Individual | CORPORATE DIRECTOR | — | since 01/01/2017 |
| STONE, ROBYN | Individual | CORPORATE DIRECTOR | — | since 01/01/2016 |
| DAVIS, TODD | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| FOX, CYNTHIA | Individual | CORPORATE OFFICER | — | since 01/01/2025 |
| HOFFMAN, CYNTHIA | Individual | CORPORATE OFFICER | — | since 06/02/2021 |
| KRIEGER, DANIEL | Individual | CORPORATE OFFICER | — | since 12/01/2023 |
| WICKLINE, BEVERLY | Individual | CORPORATE OFFICER | — | since 01/01/2025 |
| BENCHMARK THERAPIES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| CURANA HEALTH OF PENNSYLVANIA PC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| ASPINALL, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| BOWSER, NICOLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| KATZ, PAUL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| AB STAFFING SOLUTIONS LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| ADARA HEALTHCARE STAFFING, INC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| AMERGIS HEALTHCARE STAFFING, INC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| BENEVOLENT HEALTHCARE STAFFING LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| CROSS COUNTRY STAFFING, INC. | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| DEDICATED NURSING ASSOCIATES, INC. | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| EXCELLA STAFFING SOLUTIONS LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| FAVORITE HEALTHCARE STAFFING LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| GHR HEALTHCARE HOLDINGS, INC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| INFINITE HEALTHCARE SERVICES LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| READY TO HELP STAFFING LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| RKL LLP | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| RN PLUS, INC. | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| SHIFTSTER LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| TITAN NURSE STAFFING LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| TOM BARNES MBORI HEALTH SERVICES LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| TRIAGE STAFFING SOLUTIONS, INC. | Organization | ADP OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 52 rows in the source record cover these 46 parties — each is shown once here with every role it holds. Nothing is omitted.
23 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 395530. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-20, 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.