No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Rehabilitation Center At Jefferson Hills, The

540 Coal Valley Road, Jefferson Hills, PA 15025 · For profit - Individual · 50 certified beds · (412) 466-1125 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$8,281 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,281 in federal fines (most recent 2025-03-13)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

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

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
575 Coal Valley Rd · (412) 469-1500 · Call to confirm hours
Pharmacy
2000 Clairton Rd · (412) 655-2151 · Call to confirm hours
Grocery
665 Clairton Blvd · (412) 714-0003 · Call to confirm hours
Park
1201 Clairton Rd · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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.

Overall rating3★
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 increased5.8%16.8%15.4%better
Long-stay residents who lose too much weight4.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms2.0%10.8%6.5%better
Long-stay residents who were physically restrained0.9%0.2%0.1%worse
Long-stay residents with falls causing major injury2.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened5.3%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.8%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers25.3%4.8%4.7%check this — see note marked dagger below the table
Long-stay residents with worsening bladder/bowel control26.9%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table1.4%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine96.2%68.7%79.4%better
Short-stay residents rehospitalized after admission23.9%22.5%22.6%typical
Short-stay residents with an outpatient ER visit9.6%9.5%12.0%better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.

47.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.8%U.S. median 51.5%
Got home and stayed home
12.1%U.S. median 10.7%
Went back to hospital
48.9%U.S. median 56.6%
Met the expected recovery
0.66U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.32hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 48.9% 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 45 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 0.66 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 SNF47.8%CMS range 34.5–63.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.1%CMS range 8.1–17.410.7%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 discharge48.9%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 discharge60.0%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 discharge46.7%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 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 worsened3.6%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 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

1.18
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.43
Aide hours/ resident / day
4.50
Total nurse hours/ resident / day
0.68
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 50 beds and averages 44.5 residents a day — about 89% occupied, or roughly 6 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 4.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.18 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.04 hrs/resident/day on weekends vs 4.69 on weekdays — 14% thinner on weekends. RN hours go from 1.39 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

11
deficiencies at the latest standard inspection (2026-02-13)
3
at the previous standard inspection (2025-03-13)

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

Inspection deficiencies

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

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-05-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R1). This failure created an immediate jeopardy situation for 1 of 42 residents. Review of the facility policy Resident Rights dated 12/20/24, indicated the facility will promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Review of the clinical record revealed Resident R1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of the facility medical diagnosis list dated 4/28/25, included diagnoses of hemothorax (condition where blood collects in the space between the chest wall and lung), Atrial Fibrillation (condition where the upper chambers of the heart beat out of rhythm causing an irregular and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of two nursing units (North Nursing Unit).Findings include: Review of the facility policy Resident Environment dated 12/5/25, indicated in part The facility will provide an environment that is safe, clean comfortable and homelike, allowing the resident to use his or her personal belongings to the extent possible. During an observation on 02/12/2026, at 8:30 a.m., the following was identified: Residents R19 and R30 had tape surrounding the ceiling air vent. The air vent and tape had dust collected on both. Residents R4 and R41 had the rubber baseboard molding pulled away from the wall, for the entire length of the wall. Residents R26 and R40 had the rubber baseboard molding pulled away from the wall, for the entire length of the wall. Resident R26 had approximately a 30.61-millimeter hole in the wall at the outlet junction box that was in use.…

    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 · E2026-02-13 · tag F0585 — failed to handle grievances — pattern
    Honor 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 facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in three of three locations where grievances boxes are located (main lobby, north and south nursing units). Findings include: A review of the facility policy Grievances/Complaints, Filing reviewed 1/16/25, grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding…

    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 · E2026-02-13 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of scheduled activities, observations, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents. Findings include: Review of the activity's calendars for the facility, from September through February 2026 revealed there are no group activities on Sunday's. There are three activities a day listed on the calendar with the last activity at 1 pm following lunch in the dining room. Review of the Activities calendar from September 2025 through February 2026 revealed the following: Daily9:30 a.m. 1 on 1 visits by distributing the facility Daily Chronicle (document for residents to read).11:30 a.m. Lunch Monday through Friday1:00 p.m. group activity Saturday1:00 p.m. rotating cycle one Saturday puzzles, one Saturday coloring, and one Saturday games. Sunday1:00 p.m. residents' choice a cart with books, magazines and items is taken around the facility if residents want to select something to do independently. During a group…

    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 · E2026-02-13 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, personnel records, and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.Findings include: The facility Activities Director employee job description indicated; The primary purpose of the job position is to plan, organize, implement, evaluate and direct the Activity Programs in accordance with the current federal, state, and local standards governing the facility and as directed by administrator, to ensure that the emotional, recreational, and social needs of the residents are met and maintained on an individual basis. Review of Activities Director Employee E1's personnel record indicated she was hired on 1/9/25. Review of Activities Director Employee E1's personnel record did not include evidence that Activities Director Employee E1 had proper qualifications as an Activities Director. The personnel record did not include previous history as an Activity Director, education in therapeutic services, education as a social worker 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 a review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide prescribed treatments and services related to the care of pressure ulcers and/or pressure ulcer prevention for three of six residents (Resident R6, R7, and R23).Findings Include: Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality's, Safety Program for Nursing Home: On-Time Pressure Ulcer Prevention dated May 2016, indicated that Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer hospital stays and increased morbidity and mortality. Three critical components in preventing pressure ulcers were listed: comprehensive skin assessments, standardized pressure ulcer risk assessments, and care planning and implementation to address areas of risk. Review of the National Library of Medicine, The Braden Scale for Predicting Pressure Sore Risk indicated the scale was developed to foster…

    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 · E2026-02-13 · tag F0761 — failed to label and store drugs safely — pattern
    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 policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in one of two medication carts and one of two medication storage rooms (North Hall storage room and South Hall medication cart).Findings include:Review of facility policy Storage of Medications dated 12/5/25, stated that medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. During an observation of the North Unit medication room on 2/11/26, at approximately 12:00 p.m. the following was observed:59 blood collection tubes with an expiration date of 10/31/25.7 blood collection tubes with an expiration date of 1/31/25.2 vacutainers with an expiration date of 11/30/25.3 vacutainers with an expiration date of 10/31/25.8 IV start kits with an expiration date of 11/30/23.4 IV extension sets with an expiration date of 5/31/25.1 syringe with an expiration date of 9/30/24.3 syringes with an expiration date of 6/1/25.4 package…

    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 · D2026-02-13 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, it was determined that the facility failed to provide reasonable access to mail services as available in the community to all residents of the facility.Findings include: A review of the facility policy Mail last reviewed 12/5/25, indicated Delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (or facility post office box ) and delivery of outgoing mail to the postal service within 24 hours, when there is no regularly scheduled postal delivery and pick-up service. During a group interview on 2/11/26, at approximately 11:30 a.m., consensus from the group revealed that residents reported the facility did not deliver mail or provide mail services on Saturdays. Review of the facility documents (activity calendars) for the past six months from 9/25 through 2/26 reveal a statement of Mail Delivery is Monday - Friday During an interview on 2/12/26, at 1:15 p.m. Activities Director Employee E1 confirmed that she does not deliver mail on Saturday as she is not in the building on weekends and she is the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-13 · 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 observations and staff interview it was determined that the facility failed to provide a safe environment for residents in one of two nursing units (waste room and staff restroom). Findings include:During an observation on 2/11/26, at approximately 11:45 a.m. the biohazardous waste room was noted to be unlocked. Within the room were 13 sharps containers on a shelf and two large biohazardous waste bag with multiple sharps containers in them on the floor. During an observation on 2/11/26, at approximately 11:50 a.m. the beauty shop was noted to be unlocked. Within the room was an environmental services cart with cleaning supplies and a large putty knife on top. During an observation on 2/11/26, at approximately 11:53 a.m. the staff restroom was noted to be not fully closed. Observation of the restroom revealed no emergency call light or call cord attached for emergency use. During an observation on 2/12/26, at approximately 11:00 a.m. the biohazardous waste room and the staff restroom were noted to be unlocked and accessible to residents. During an observation on 2/13/26, 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 · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and resident and staff interviews it was determined that the facility failed to make certain that showers and baths were provided for one of three residents (Resident R37). Findings include: Review of facility policy Resident Rights reviewed 12/20/24, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of facility policy Flow of Care reviewed 12/20/24, indicated care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. Residents are to have two bath/showers/week unless the resident states otherwise. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE], with diagnoses that included repeated falls, diabetes, and low blood pressure. Review of Resident R37' s Minimum Data Set (MDS - a mandated assessment of a resident'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for two of five residents reviewed (Residents R20 and R24). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited before2025-03-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of six residents reviewed (Resident R37). Findings: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE], with diagnoses that included repeated falls, diabetes, and low blood pressure. Review of Resident R37' s Minimum Data Set (MDS - a mandated 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the family of a change in condition in a timely manner for one of four residents (Resident R1). Findings include: Review of the facility policy Notification of Change Condition: Responsible Party/Guardian dated 5/1/24, indicated the responsible party or guardian is to be notified when there has been any break in the resident's skin integrity. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia and a fractured left leg. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/24, indicated the diagnoses remain current. Review of Resident R1's admission assessment dated [DATE], indicated the resident had a skin alteration to the coccyx (lower back) 0-0.3 cm (centimeters) with light exudate (abrasion) and granulated (healing) tissue. Review of Resident R1's nurse progress note…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R1) Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia, and a left leg fracture. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 7/4/24, indicated the diagnoses remain current. Review of a physician order dated 7/15/24, indicated to cleanse the top of both feet with NSS (normal saline solution), apply Xeroform (a moisture dressing) to open areas, apply 4X4 gauze, and wrap with gauze daily for wound care. Review of Resident R1's Treatment Administration Record (TAR), dated July 2024, indicated the treatment was applied on 7/16, and 7/17/2024. Resident R1 was discharged to home on 7/17/24. Review of weekly skin check documentation dated, 06/28/24, 7/3/24,…

    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 · F2024-03-07 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documents, resident and staff interviews it was determined that the facility failed to ensure the residents' right to not enter into a binding arbitration agreement as a condition of admission for 44 of 44 admitted residents. Findings include: Review of the admission Packet list attachments as Attachment P Voluntary Arbitration Agreement. Review of the Arbitration Agreement indicated that the agreement is voluntary. The agreement has been explained to the Resident and his or her Representative in a form and manner that he or she understands. The signature section at the end of the agreement stated THE EXECUTION PAGE MUST BE SIGNED BY EITHER THE RESIDENT OR THE RESIDENT'S REPRESENTATIVE. This section did not include options to agree or disagree to enter into the binding arbitration agreement, or a refusal to sign. Review of facility census information indicated 44 residents were admitted to the facility from 1/1/24, through 3/7/24. During an interview on 3/7/24, at 11:00 a.m. Business Office Manager (BOM) Employee E2 confirmed that all residents sign the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-07 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia) for eleven of eleven months (April 2023 through February 2024). Findings include: A review of the facility policy Legionnaires' Disease Infection Control and Monitoring Policy dated 2/12/24, did not include a water management program based on framework outlined in ASHRAE and CDC Standards identified as per the Maintenance Director Employee E1 and confirmed with the Nursing Home Administrator to minimize risk for Legionella associated with the building water systems at The Rehabilitation Center at [NAME] Hills. During an interview on 3/7/24, at 1:00 p.m., Maintenance Director Employee E1 and the Nursing Home Administrator confirmed that the facility did not implement and effective water management program for the prevention and control of water-borne…

    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 · E2024-03-07 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 a review of facility documentation and staff and resident interviews, it was determined the facility failed to ensure the provision of a substantial evening snack to the residents when up to 16 hours elapsed from the supper meal to breakfast the next day, and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours. Findings include: Review of facility's scheduled meal times revealed meal times revealed greater than 14 hours between dinner and breakfast. Breakfast: North Unit 9:00 a.m.; South Unit 9:10 a.m. Lunch: North Unit 1:00 p.m.; South Unit 1:10 p.m.; Dining Hall 1:15 p.m. Dinner: North Unit 5:00 p.m.; South Unit 5:10 p.m. During a resident group interview on 3/5/24, at 2:00 p.m. the residents stated that snacks at night are usually potato chips or snack puddings. On 3/7/24, at approximately 10:30 a.m. documentation was requested from Activities Director Employee E3 that the resident group agreed to this meal span. During an interview on 3/7/24, at approximately 2:00 p.m.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-07 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator for 44 of 44 residents admitted . Findings include: Review of facility's admission Agreement packet, which contained the document Voluntary Arbitration Agreement indicated that Accordingly, any dispute arising out of relating to the provision of services by the Facility to the Resident, Resident's admission to the Facility, Resident's contracts with the Facility or the subject matter thereof, any breach of contract, including any dispute regarding the execution, validity or scope of this Arbitration Agreement or any of its clauses, will be resolved through arbitration administered by [name of arbitrator services company which the facility utilized] and conducted pursuant to the [arbitrator] Rules of Procedure for Arbitration. The facility's arbitration agreement failed to provide 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-07 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for three of three nurse aides (Employees E4, E5, and E6). Finding include: Review of the policy Staff Development dated 12/11/23, previously reviewed 7/1/23, indicated Nursing assistants shall receive at least 12 hours of in-service per year. Review of Nurse Aide (NA) Employees E4, E5, and E6 education records revealed that each NA had documentation of eight hours of in-service training, and additional plan of correction training on abuse and neglect, visitation, and transfer status. During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of the required 12 hours annual in-service education within 12 months of their hire date anniversary for three of three nurse aides. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications and failed to provide medications in accordance with manufacturer's instructions for use for one of five residents (Resident R37). Findings include: Review of the U.S. Food and Drug Administration (FDA) prescribing information for Ziprasidone (anti-psychotic medication) revised 01/2020, indicated that Ziprasidone is used for the treatment of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and bipolar disease (a mental condition marked by alternating periods of elation and depression). Further review of this documented indicated this medication is to be given with food. Review of the U.S. National Library of Medicine The Impact of Calories and Fat Content of Meals on Oral Ziprasidone Absorption dated 10/21/08, indicated that Ziprasidone should…

    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 before2024-03-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of five residents (Resident R35). Findings include: Review of the facility policy Pressure Ulcer Review dated 12/11/23, previously reviewed 7/1/23, indicated that a resident with a pressure ulcer receives the necessary treatment and services to promote healing, prevent infections, and prevent new development. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/31/24, included the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and Down syndrome (a genetic disorder causing developmental and intellectual delays). Review of a physician's order dated 1/3/24, to start on 1/4/24, indicated for staff to cleanse coccyx…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent avoidable falls for one of five residents reviewed (Resident R7), and failed to document the appropriate assistance level for seven of eighteen residents (R8, R9, R10, R11, R12, R13, and R14) Findings include: Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/29/23, revealed diagnoses of high blood pressure, and syncope and collapse (loss of consciousness with subsequent fall). Review of Section G: Functional Status indicated Resident R7 required extensive assistance of two or more persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident R7's physician orders dated 10/8/22, indicated Transfers with assist x2. Review of Resident R7's [NAME] (document 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record and staff interviews it was determined that the facility failed to make certain that appropriate treatment and services were provided for three of six residents with a urinary catheter (Resident R4, R5, and R6). Findings include: Review of the Centers for Disease Control guidance Guideline for Prevention of Catheter-Associated Urinary Tract Infections updated 6/6/19, indicated to not rest the collecting bag on the floor. The facility policy Catheter Care dated 7/1/23, indicated catheter care is provided to prevent infection and reduce irritation. Review of admission record indicated that Resident R4 was admitted on [DATE]. Review of Resident R4's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 9/26/23, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and history of a stroke. Review of a physician's order dated 9/29/23, indicated the insertion of 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 · E2023-12-01 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for three of four residents (Residents R1, R2, and R3). Findings include: Review of the facility census information indicated Resident R1 was admitted to the facility on [DATE]. Review of the facility diagnosis list included rheumatoid arthritis (chronic, painful inflammatory disorder affecting many joints, including those in the hands and feet) and aftercare following joint replacement surgery. Review of a physician's order dated 9/29/23, written at 12:52 p.m. indicated Resident R1 was to receive gabapentin (medication that can be used to treat pain) 100 mg (milligrams) by mouth every 24 hours as needed pain. Review of a physician's order dated 9/29/23, written at 1:37 p.m. indicated Resident R1 was to receive oxycodone (opioid medication to relieve pain) 10 mg by mouth every six hours as needed for severe pain. Review of a physician's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-01 · tag F0563 — failed to protect the right to visitors — isolated
    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility documents and staff interviews, it was determined that the facility failed to ensure that the residents were aware of unrestricted visitation for one of five residents (Resident R1). Findings include: During an observation on 12/1/23, at 9:00 a.m. signage was posted on the entry door which indicated visiting hours were restricted to 9:00 a.m. to 9:00 p.m. daily. During an observation on 12/1/23, at 9:01 a.m. signage was posted at the visitor sign in table which indicated visiting hours were restricted to 9:00 a.m. to 9:00 p.m. daily. Review of an employee statement dated 10/3/23, at 10:55 p.m. indicated The gentleman (spouse of Resident R1) was returning the bathroom key when I addressed him by name and introduced myself and my position as night shift supervisor. I pleasantly informed him that we have visiting hours and we ask visitors to adhere to them. The statement further indicated, People live here and for their safety, healing, and care we ask people to abide by the visiting hours; especially if they have a roommate. Only family members of people…

    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
  • No harm found · B2026-02-13 · tag F0579 — pattern
    Provide information about how to apply for and use Medicare and Medicaid benefits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building, where postings are available (first floor lobby). Findings include: The facility must display in the facility, written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During observations completed on 2/11/26, at approximately 11:30 a.m., in the lobby, hallways in and around the nursing units, revealed the facility failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During rounds and an interview with the Nursing Home Administrator (NHA) on 2/12/26, at 9:00 a.m., the NHA…

    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
  • No harm found · Bcited before2026-02-13 · tag F0941 — pattern
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for nine of thirteen staff members (Employee E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, and E15).Findings include: Review of the facility policy, Staff Development Program most recently reviewed 12/5/25, indicated, There shall be an ongoing coordinated education program which is planned and conducted for the development and improvement of skills of the facility personnel, including training related to technology, problems, needs and rights of residents Review of facility provided documents and training records revealed the following staff members did not have documented training on the resident rights Program. Nurse Aide Employee E5 had a hire date of 10/24/25, and failed to have resident rights education upon hire or thereafter.Nurse Aide Employee E6 had a hire date of 11/23/25, and failed to have resident rights education upon hire or thereafter.Nurse Aide Employee E7 had a hire date of 2/5/24, failed to…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-02-13 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for eleven of fifteen staff members (Employee E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, and E15).Findings include: Review of the facility policy, Staff Development Program most recently reviewed 12/5/25, indicated, There shall be an ongoing coordinated education program which is planned and conducted for the development and improvement of skills of the facility personnel, including training related to technology, problems, needs and rights of residents Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI Program. Nurse Aide Employee E5 had a hire date of 10/24/25, and failed to have QAPI education upon hire or thereafter.Nurse Aide Employee E6 had a hire date of 11/23/25, and failed to have QAPI education upon hire or thereafter.Nurse Aide Employee E7 had a hire date of 2/5/24,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-03-07 · tag F0941 — widespread
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of facility policy and staff interviews, it was determined that the facility failed to provide training on effective communication to facility staff. Findings include Review of the policy Staff Development dated 12/11/23, previously reviewed 7/1/23, indicated the facility will provide all active employees with required training and education to include mandatory and corporately recommended staff training programs. Review of faciltiy provided education documents failed to include that provision of training the facility staff on Effective Communication. During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide training on effective communication to facility staff. 28 Pa. Code 201.20(a)(b)(c)(d) Staff Development.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-03-07 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of facility policy and staff interviews, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program to facility staff. Findings include Review of the policy Staff Development dated 12/11/23, previously reviewed 7/1/23, indicated the facility will provide all active employees with required training and education to include mandatory and corporately recommended staff training programs. Review of faciltiy provided education documents failed to include that provision of training the facility staff on the QAPI program. During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide training on the QAPI program to facility staff. 28 Pa. Code 201.20(a)(b)(c)(d) Staff Development.

    Administration Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$8,281 in federal fines across 1 penalty.

  • $8,281 — penalty dated 2025-03-13

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.

Who owns this facility

Owner / managerTypeRoleShareSince
FERRARO, DAVIDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER100%since 12/10/2023

CMS files one row per role, so the 3 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$2.2M
Net patient revenuemost recent cost report
-23.9%
Operating marginrevenue minus expenses
$264K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 2%Other / private 15%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $264K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$387per resident / day
operating cost
$11,775per month
≈ monthly operating cost
$313per 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 395948. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-13, 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.

What to do next