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Westminster Woods At Huntingdo

360 Westminster Drive, Huntingdon, PA 16652 · Non profit - Corporation · 64 certified beds · (814) 643-3160 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1225 Warm Springs Ave · (814) 643-2290 · Call to confirm hours
Pharmacy
611 15th St · (814) 643-2743 · Call to confirm hours
Grocery
611 15th St · (814) 643-2743 · Call to confirm hours
Park
698 16th St · (814) 643-3966 · Typically dawn to dusk
Place of worship
2340 Miller Ave · (814) 643-3370

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased26.9%16.8%15.4%worse
Long-stay residents who lose too much weight11.1%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.2%0.7%0.9%worse
Long-stay residents with a urinary tract infection3.1%1.5%2.0%worse
Long-stay residents with depressive symptoms2.2%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.1%3.1%3.3%typical
Long-stay residents whose ability to walk worsened28.1%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.9%20.0%18.9%typical
Long-stay residents given the seasonal flu vaccine94.0%93.5%95.3%typical
Long-stay residents with pressure ulcers9.0%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control32.4%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.1%17.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine50.0%68.7%79.4%worse
Short-stay residents rehospitalized after admission23.3%22.5%22.6%typical
Short-stay residents with an outpatient ER visit10.8%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days0.771.621.67better
Long-stay outpatient ER visits per 1,000 resident days2.321.181.80worse

§ 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.

36.2% 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 94 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.2%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
67.9%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 67.9% 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 28 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.2%CMS range 27.2–44.551.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.1–13.310.7%Oct 2022–Sep 2024no 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 discharge67.9%56.6%Oct 2024–Sep 2025CMS 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 discharge57.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.3%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 4.0–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.731.02Oct 2022–Sep 2024CMS 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

0.70
RN hours/ resident / day
0.96
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.69
Total nurse hours/ resident / day
0.43
RN hoursweekends
38.3%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 64 beds and averages 59.4 residents a day — about 93% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.48 hrs/resident/day on weekends vs 3.78 on weekdays — 8% thinner on weekends. RN hours go from 0.81 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-05-07)
7
at the previous standard inspection (2025-04-03)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of four residents reviewed (Resident 2) resulting in aspiration. This deficiency is being cited as past non-compliance. Findings include: A comprehensive minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 2, dated May 11, 2026, revealed that the resident was severely cognitively impaired, required assistance from staff, and had a mechanical diet. A care plan for activities of daily living, dated July 3, 2025, indicated that Resident 2 required set-up by staff to eat, needed to be encouraged to eat meals in the dining room, and to supervise meals and monitor for pocketing of food. A speech therapy discharge summary for Resident 2, dated April 23, 2026, recommended skilled treatment interventions focused on education and training patient and caregivers in safe swallowing strategies in order to safely tolerate least restrictive diet. It was also recommended for the patient to sit at…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-05-07 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete a thorough investigation for a choking incident that occurred for one of 17 residents reviewed (Resident 17). Findings include:A facility policy for abuse and neglect dated January 9, 2026 , revealed that events involving evidence or reports of physical, sexual, mental or verbal abuse involuntary seclusion, neglect and misappropriation or resident's property shall be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 hours or within the timeframe that has been identified. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 2, 2026, revealed that the resident was cognitively impaired, required a mechanically altered diet, did not have coughing or choking during meals or when swallowing medication, was dependent on staff with daily care needs, and required partial…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of investigative reports, and residents' clinical records, observations, as well as staff interviews, it was determined that the facility failed to ensure physician's orders were followed for four of 30 residents Reviewed (Residents 1, 22, 33, and 55). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2026, indicated that the resident was severely cognitively impaired and required supervision or touching assistance for eating, had a unexpected weight loss, and had diagnoses that included malnutrition. A nutritional care plan dated March 22, 2026 indicated that supplements were to be administered as ordered.Physician's orders for Resident 1, dated October 4, 2025 , included an order for the resident to receive a magic cup (nutrient-dense, high-calorie frozen dessert) twice a day for a recent significant weight loss, with additional orders to instructions to include the amount consumed.A…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0628 — isolated
    Provide 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 clinical record review, as well as staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for transfer to the hospital and to ensure that a bed-hold notice was provided to the resident's responsible party for one of 17 residents reviewed (Resident 23).Findings Include: A nursing note for Resident 23 dated February 6, 2026, revealed that the resident was found lethargic, mumbling, diaphoretic, unable to answer questions appropriately, and pupils were non-reactive and fixed. She was subsequently sent to the emergency room for evaluation. Review of Resident 23's clinical record revealed no documented evidence that the resident representative notified in writing of the transfer to the hospital on the above dates and times, and that a bed hold notice was not provided at the time of the transfer. Interview with the Nursing Home Administrator on May 6, 2026, at 10:09 a.m. revealed that she did not notify the resident's representative of the hospital transfer for the resident's above, and that the bed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that that the physician was notified of a weight change for two of 30 residents reviewed (Residents 1 and 22).Findings Include: A facility policy regarding weights, dated December 29, 2025, revealed that variances of plus or minus five pounds or more for residents over 100 pounds requires a reweigh in 24 hours, a report by the charge nurse to the physician, dietician, and responsible party. The dietician will initiate approaches to remedy the change in weight.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2026, indicated that the resident was severely cognitively impaired and required supervision or touching assistance for eating, had a unexpected weight loss, and had diagnoses that included malnutrition. A nutritional care plan for the resident, dated March 22, 2026 indicated the Registered Dietitian would monitor weights and average meal intakes.On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 30 residents reviewed (Resident 4).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated April 4, 2026, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. A review of Resident 4's care plan, dated July 16, 2025, indicated that the resident had PTSD, anxiety, and Traumatic Brain Injury. There was no documented evidence the facility identified Resident 4's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 30 residents reviewed (Resident 3).Findings include:An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 8, 2026, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and was taking opioid medication. A care plan for Resident 3 dated January 29, 2026, indicated that she would display pain by yelling out. Nursing was to assess her pain and administer pain medications as ordered. Physician's orders for Resident 3, dated February 3, 2026 , included an order for the resident to receive one 5 milligram (mg) tablet of Oxycodone (narcotic pain medication) every four hours as needed for pain. A review of Resident 3's Controlled Drug Record (a legally required document that tracks every transaction of the medication to prevent diversion and ensure regulatory compliance), dated February…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of three residents reviewed (Resident 1). Findings include: The facility's abuse policy, dated December 22, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall be protected from mistreatment, neglect, exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 2, 2026, indicated that the resident was cognitively intact, was understood and could understand others, was dependent on staff for daily care needs, was incontinent of bowel and bladder and had diagnoses that included vascular Amyotrophic Lateral Sclerosis (a progressive, fatal neurodegenerative disease that destroys motor neurons in the brain and spinal cord, causing loss of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-03 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to store frozen foods appropriately, failing to keep kitchen equipment clean and sanitary, and failing to have staff wear appropriate hair restraints during food preparation and tray line service. Findings include: The facility's policy regarding food labeling and dating, dated January 22, 2024, revealed staff were to properly seal the container of bulk freezer items like frozen vegetables to maintain their integrity. Observations in the kitchen's walk in freezer on March 31, 2025, at 9:20 a.m. revealed that there was an opened box of frozen fish fillets that was exposed to the air. Interview with the Dietary Director at the time of the observation confirmed that the box of frozen fish should have been sealed and removed the box to have staff cover the fish filets. The facility's policy regarding sanitizing…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about changes in diet consistencies for one of 34 residents (Resident 10) reviewed and failed to notify the urologist regarding symptoms of a urinary tract infection (UTI) for one of 34 residents (Resident 22). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated March 11, 2025, indicated that the resident was cognitively intact, was dependent on staff for care needs, and had a mechanically altered diet. A nurse's note for Resident 10, dated October 4, 2024, revealed that the resident was observed choking on water during medication administration and was downgraded from thin liquids to nectar thick as a nursing measure. A note from speech therapy, dated October 29, 2024, revealed that Resident 10 was safe to ingest nectar thick liquids. There was no documented evidence that Resident 10's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-04-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 clinical records, as well as staff interviews, it was determined that the facility failed to develop a care plan for a Peripherally Inserted Central Line (PICC) to treat an infection that required the use of intravenous antibiotics for one of 34 residents reviewed (Resident 66). Findings include: According to admission paperwork for Resident 66, dated March 19, 2025, the resident was admitted from the hospital for further care of his left heel wound on March 19, 2025. Physician's orders for Resident 66, dated March 19, 2025, included an order for the resident to receive 1 gram of Ertapenem (antibiotic) once daily through his PICC line. There was no documented evidence in Resident 66's clinical record to indicate that a care plan was developed for the care and treatment of a PICC line, infection, or IV antibiotics. Interview with the Nursing Home Administrator on April 2, 2025, at 9:02 a.m. confirmed that a care plan for Resident 66's PICC line, infection, and IV antibiotics was not developed. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(5)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 34 residents reviewed (Resident 16). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated January 22, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included heart failure and high blood pressure. Physician's orders for Resident 16, dated August 17, 2024, included orders for the resident to receive 6.5 milligrams (mg) of Carvedilol (treats high blood pressure) once a day, to be held if his apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) is less than 50 beats per minute (bpm), and to administer 5 mg lisinopril (treats high blood pressure) daily. A review of the January, February, and March 2025 Medication Administration Record (MAR) for Resident 16 revealed the following: On January 6, 2025, no apical pulse was obtained…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a privacy cover was provided for one of 34 residents reviewed (Resident 54) who had an indwelling urinary catheter. Findings include: The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine) insertion indicators, dated January 22, 2025, revealed that indwelling urinary catheters must be covered and placed below the bladder for proper drainage. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated March 13, 2025, revealed that the resident was cognitively intact, had an indwelling urinary catheter, and had diagnoses that included obstructive uropathy (normal flow of urine through the urinary tract is blocked) and benign prostatic hyperplasia (BPH - enlarge prostate). Physician's orders for Resident 54, dated March 7, 2025, included an order for the resident to have 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medication appropriately for one of 34 residents reviewed (Resident 23). Findings include: The facility's policy regarding medication storage, dated January 22, 2025, indicated that medications for internal use were stored in medication carts or other designated areas. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated March 20, 2025, indicated that the resident was cognitively intact, usually understood and could usually understand, required assistance from staff for daily care needs, and was receiving antipsychotic medication. Physician's orders for Resident 23, dated January 13, 2025, included an order for the resident to receive 25 milligrams (mg) of Seroquel (antipsychotic medication) daily for psychosis. Interview and observations of Resident 23 on March 31, 2025, at 10:55 a.m. revealed that she was in her room and she stated that her only…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 each resident was offered and/or received the pneumococcal vaccine (prevents bacterial pneumonia) for one of 34 residents reviewed (Resident 5), and failed to ensure that each resident was offered and/or received the influenza vaccine for two of 34 residents reviewed (Residents 11, 14). Findings include: The facility's policy regarding vaccines, dated January 22, 2025, revealed that the resident or the resident's representative have the opportunity to accept or refuse immunization. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2025, indicated that the resident was cognitively intact and that the resident's pneumococcal was not up to date. A pneumococcal vaccine authorization form signed by Resident 5, dated November 19, 2024, revealed that she wanted to have the pneumococcal vaccine. An interview with the Registered Nurse Assessment…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from sexual abuse for one of four residents reviewed (Resident 2). This was cited as past non-compliance. Findings include: The facility's abuse policy, dated January 22, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall be protected from mistreatment, neglect, exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 10, 2025, indicated that the resident was severely cognitively impaired, was rarely understood and could sometimes understand others, was ambulatory, and had diagnoses that included vascular dementia (memory loss). Review of information submitted by the facility, dated March 7, 2025, indicated that Maintenance Worker 1 was observed by…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-03-14 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from being recorded on a personal cell phone without their permission for one of four residents reviewed (Resident 2). Findings include: The facility's abuse policy, dated January 22, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall be protected from mistreatment, neglect exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 10, 2025, indicated that the resident was severely cognitively impaired, was rarely understood and could sometimes understand others, was ambulatory, and had diagnoses that included vascular dementia (memory loss). Review of information submitted by the facility, dated March 7, 2025, indicated that Maintenance Worker 1 was…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-29 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: The facility's policy for abuse, dated Janaury 8, 2025, indicated that the incident report process requires a note in the clinical record and subsequent documentation of all assessments and interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 6, 2024, revealed that the resident was cognitively impaired, could usually understand, was understood, was independent with daily care, and had diagnoses of stroke. A nursing note for Resident 1, dated January 18, 2025, at 10:08 a.m., revealed that the resident was found on the floor, had no complaints of pain, no injury was voiced or noted, and neurological checks (a series of tests that assess the function of the nervous system) were ordered. A review of the facility's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address a resident's frequent urinary tract infections and medication use for one of three residents reviewed (Resident 1). Findings include: The facility's policy regarding care planning, dated March 26, 2024, revealed that the comprehensive care plan was to have input from interdisciplinary team members, and to the extent practicable, the participation of the resident and/or the resident's representative(s). The care plan was to contain interdisciplinary approaches, be oriented toward involving the resident, and address additional areas that are relevant to meeting the resident's needs in the long-term care setting. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 7, 2024, indicated that the resident was understood and could usually understand, required assistance…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-16 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for two of 31 residents reviewed (Residents 3, 14). Findings include: The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that the comments and recommendations concerning medication therapy were to be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendations directed to him/her within 30 days from the date the facility receives the recommendations, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. Review of the clinical records for Resident 3 and Resident 14 revealed no documented evidence that the monthly review of medications by the pharmacist were addressed by the physician or designee in December 2023 and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 31 residents reviewed (Resident 48). Findings include: The facility policy regarding privacy of health information, dated March 26, 2024, indicated that the facility was to protect the confidentiality of a resident's health information. Observations during medication administration on May 14, 2024, at 8:21 a.m. revealed that Licensed Practical Nurse 3 walked away from her medication cart to take the blood pressure of Resident 48 without securing her computer screen. Resident 48's personal health information was visible on the computer screen, which was facing the hallway. Upon return to the cart after obtaining the blood pressure, Licensed Practical Nurse 3 retrieved medication to administer to Resident 48 and again left the computer screen unsecured with Resident 48's personal health information visible and facing the hallway. Interview with Licensed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to further assess an elevated blood pressure for one of 31 residents reviewed (Resident 29). Findings include The facility's policy regarding vital signs, dated March 26, 2024, revealed that vital signs are a measure of a resident's condition that assist in providing necessary services. The American Medical Association, Best Practice guidelines for blood pressure, dated December 2018, revealed that providers need to be aware of blood pressures that are out of range so they can act rapidly to intervene as appropriate. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated March 26, 2024, revealed that the resident was moderately cognitively impaired, usually understood and understands, and had diagnoses that include chronic kidney disease and primary hypertension (high blood pressure).…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 31 residents reviewed (Resident 47). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 47, dated March 29, 2024, revealed that the resident was cognitively impaired, required moderate assistance for all of her care, and used a wheelchair. Observations on May 13, 2024, at 11:44 a.m. revealed that Registered Nurse 4 pushed Resident 47 in a wheelchair without any leg/foot rests from her room through the hallway and into the dining room while the resident elevated her feet. The leg/foot rests were not on the resident's wheelchair. An interview with Registered Nurse 4 on May 13, 2024, at 11:47 a.m. revealed that she was aware that leg rests were to be used when transporting Resident 47 in her wheelchair. An interview with 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy, federal regulations, and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of 31 residents reviewed (Resident 14). Findings include: The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that comments and recommendations concerning medication therapy would be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendations directed to him/her within 30 days from the date the facility receives the recommendations, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. Federal Regulations require that as-needed orders for psychotropic drugs be limited to 14 days. Except when the attending physician or prescribing practitioner believes that it is…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-16 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart, failed to ensure that controlled medications were stored in a separately locked, permanently-affixed compartment in one of two medication refrigerators reviewed (Main), failed to label medications with the date they were opened in one of two medication rooms reviewed (Main Medication Room) and in one of two medication carts reviewed (200 hall). Findings include: The facility's policy regarding the security of the medication cart, dated March 26, 2024, indicated that the nurse was to secure the medication cart during the medication pass to prevent unauthorized entry, and the medication cart was to be securely locked at all times when out of the nurse's view. Observations on May 14, 2024, at 8:21 a.m. revealed that a medication cart in the hallway was unlocked and unattended by Licensed Practical Nurse 3 when she went into Resident 47's room to take his blood pressure and again at 8:25 a.m. when…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of clinical records and facility reports, as well as staff interviews, it was determined that the facility failed to have adequate supervision and interventions in place to prevent elopement for two of two residents reviewed (Residents 1, 2) who were identified as at risk for elopement. This deficiency was cited as past non-compliance. Findings include: A nursing note for Resident 1, dated January 15, 2024, at 3:23 p.m., revealed that the resident arrived at the facility at 2:00 p.m. via wheelchair with a diagnosis of altered mental status. His mobility status was supervision with a folding wheeled walker. He was alert to self and knew that he was about 10 miles past his house. Discharge plans for the resident was for short-term rehabilitation and return home when he is ready for discharge. An Elopement Risk for Resident 1, dated January 15, 2024, at 3:12 p.m., revealed that the resident scored a 10, indicating that the resident was at risk for elopement. A nursing note for Resident 1, dated January 15, 2024, at 4:17 p.m., revealed that the resident's elopement…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance

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

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

Fines & penalties

No federal fines in the current CMS record.

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 →

RatingThis homeChain avg
Overall 2 of 53.6-1.6 vs chain
Health inspection 2 of 53.2-1.2 vs chain
Staffing 3 of 54.0-1.0 vs chain
Quality measures 2 of 53.5-1.5 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 / managerTypeRoleShareSince
PHIOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 01/01/2025
PRESBYTERIAN HOMES IN THE PRESBYTERY OF HUNTINGDONOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2025
BIRDSALL, JAMESIndividualCORPORATE DIRECTOR; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 01/01/2023
CHOTTINER, LAWRENCEIndividualCORPORATE DIRECTORsince 01/01/2023
DAVIS, DANNYIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 01/01/2025
DENISON, BARBARAIndividualCORPORATE DIRECTORsince 01/01/2024
DERR, SCOTTIndividualCORPORATE DIRECTORsince 01/01/2025
ELLIOTT, BRENDAIndividualCORPORATE DIRECTORsince 01/01/2022
GOLDSTEIN, TERRYIndividualCORPORATE DIRECTORsince 01/01/2018
HERSHEY, KATHERINEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2025
KELLY, SHARONIndividualCORPORATE DIRECTORsince 01/01/2011
KINARD, JOSEPHIndividualCORPORATE DIRECTORsince 01/01/2021
KRIEGER, DANIELIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2025
MCALISTER, DYANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2025
PAXTON, STUARTIndividualCORPORATE DIRECTORsince 01/01/2019
REIMANN, SUSANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2016
RHODES, CHERYLIndividualCORPORATE DIRECTORsince 01/01/2024
SCOTT, WILLIAMIndividualCORPORATE DIRECTORsince 01/01/2024
SEIBERT, JOSEPHIndividualCORPORATE DIRECTORsince 01/01/2023
SHROPSHIRE, JENNIFERIndividualCORPORATE DIRECTORsince 01/01/2017
STONE, ROBYNIndividualCORPORATE DIRECTORsince 01/01/2016
DAVIS, TODDIndividualCORPORATE OFFICERsince 06/01/2024
FOX, CYNTHIAIndividualCORPORATE OFFICERsince 01/01/2025
HOFFMAN, CYNTHIAIndividualCORPORATE OFFICERsince 06/02/2021
WICKLINE, BEVERLYIndividualCORPORATE OFFICERsince 01/01/2025
BENCHMARK THERAPIES, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
CURANA HEALTH OF PENNSYLVANIA PCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
BOWSER, NICOLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/01/2011
KATZ, PAULIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
ROBINSON, TARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
AB STAFFING SOLUTIONS LLCOrganizationADP OF THE SNFsince 01/01/2025
BAKER TILLY ADVISORY GROUP LPOrganizationADP OF THE SNFsince 01/01/2025
CROSS COUNTRY STAFFING, INC.OrganizationADP OF THE SNFsince 01/01/2025
HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INCOrganizationADP OF THE SNFsince 01/01/2025
INFINITE HEALTHCARE SERVICES LLCOrganizationADP OF THE SNFsince 01/01/2025
RKL LLPOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 47 rows in the source record cover these 36 parties — each is shown once here with every role it holds. Nothing is omitted.

10 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.

$11.1M
Net patient revenuemost recent cost report
-4.8%
Operating marginrevenue minus expenses
$1.8M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 6%Other / private 39%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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.

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

$568per resident / day
operating cost
$17,278per month
≈ monthly operating cost
$542per day
avg. revenue, all payers

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

Paying with Medicaid

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.

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 396015. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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