Neffsville Nursing And Rehabilitation
2829 Lititz Pike, Lancaster, PA 17601 · For profit - Corporation · 240 certified beds · (717) 569-3211 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,516 in federal fines (most recent 2026-01-02)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 25% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 29.2% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.8% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.7% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 10.1% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.3% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 23.8% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.3% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.3% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 27.8% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.5% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 70.3% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.6% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.1% | 9.5% | 12.0% | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.3% 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 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.5% 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 43 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 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.3%CMS range 39.6–58.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.7–15.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 44.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 72.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.3–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 240 beds and averages 201.8 residents a day — about 84% occupied, or roughly 38 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.34 on weekdays — 11% thinner on weekends. RN hours go from 0.61 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Kcited before2026-02-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observation, record review, and staff interviews, it was determined the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents. Specifically, the facility utilized radiant space heaters in resident rooms and in a hallway of the rehabilitation unit following loss of heat, placing residents, including residents with cognitive impairment, at risk for serious injury or death. This failure constituted Immediate Jeopardy for the 22 residents on the Rehab unit.Findings include:During an interview conducted with the Nursing Home Administrator (NHA) on February 3, 2026, at approximately 8:20 a.m., the NHA reported one hallway in the rehabilitation unit lost heat on the evening of January 31, 2026. In response, the facility placed three radiant space heaters in resident rooms and two radiant space heaters in the rehabilitation unit hallway.Observations conducted February 3, 2026, at 8:24 a.m., during the survey revealed radiant space heaters actively in use in resident rooms and in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-09-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy and procedure review, staff interview, clinical record review, and facility documentation review it was determine the facility failed to ensure that one of three residents reviewed was free from free from accidents and provided adequate supervision resulting in actual harm of a distal femur fracture of Resident 1. Findings include: Review of Resident 1's diagnosis list revealed a diagnosis of Obesity, history of falling, hip fracture, Muscle Weakness, CVA (Cerebral Vascular Accident- Stroke) and Dementia (group of conditions that cause a decline in cognitive function, including memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life). Review of Resident 1's Minimum Data Set (MDS-periodic assessment of resident needs) dated May 5, 2025, revealed the resident was cognitively intact. Review of Resident 1's Care Plan revealed a care plan for ADL (Activities of Daily Living- basic self-care tasks that individuals perform on a regular basis to maintain their health and independence) self-care performance deficit r/t…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-04 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of employee job descriptions, as well as observations, record review, and staff interviews, it was determined that the facility's administration, including the Nursing Home Administrator and Director of Nursing, failed to effectively utilize available resources to promote resident safety and maintain the highest practicable physical well-being of residents. Specifically, the facility failed to ensure the environment was free from accident hazards by permitting the use of radiant space heaters in resident rooms and hallways, including areas accessible to residents with cognitive impairment. This failure placed residents at risk for serious injury or death and resulted in an Immediate Jeopardy situation.Findings include: The job description for the Nursing Home Administrator (NHA), dated October 06, 2025, indicated the NHA's primary purpose is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-03 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observations, staff interview, and resdient interview it was determined the facility failed to maintain a clean, comfortable, and homelike environment in four of four resident bathrooms. (Apple, Rosemont, [NAME] and Rehab units)Findings Include:Observation of the Apple unit bathroom on October 17, 2025 at 11:15 a.m. revealed the floor of the shower was missing approximately 8 tiles and the corner of the wall separating the bathtub and the shower had broken and missing tiles.Observations of the Rosemont unit bathroom on October 17, 2025 at 11:20 a.m. revealed a soiled Band-Aid lying on the floor of the shower. The wall of the entrance to the shower was broken at the floor with missing tiles and the metal covering bent and sticking out. The wall next to the entrance to the bathroom was missing tiles and had broken tiles.Observations of the [NAME] unit bathroom on October 17, 2025 at 11:25 a.m. revealed a plastic light cover was broken and lying on the floor by the entrance door of the bathroom.Observation of the Rehab unit bathroom on October 17, 2025 at 11:30 a.m. revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, clinical records review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards when the facility failed to notify the physician of recommendations following a specialist consultation for one out of 1 resident reviewed (Resident 2). Review of Resident 2's clinical records reveal medical diagnoses that include: Spina bifida (a birth defect that mainly affects the spine), hydrocephalus (a complication that can be associated with spina bifida causing the abnormal buildup of the fluid that surrounds the brain), neurogenic bladder (a problem with the brain, nerves, or spinal column that causes loss of control of the bladder that can be associated with spina bifida), and neurogenic bowel (difficulty moving or controlling the bowels because of nerve damage that can be associated with spina bifida).Review of Resident 2's clinical record revealed an after-visit summary dated January 3, 2025 from a Spina bifida specialist to the attention of the Nursing Supervisor stating: Please…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility policy and procedure review, observations, and staff interview it was determined the facility failed to maintain a sanitary environment in the kitchen. Findings Include: Review of facility policy and procedure titled Cleaning and Sanitation of Food Service Area, last revised July 2023 revealed the food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Observation of the dishwashing area on March 25, 2025 at 2:45 p.m. revealed a large brown colored substance covering the wall behind the dishwashing machine. Interview with Dietary Employee E3 on March 25, 2025 at 3:10 p.m. confirmed that the walls were dirty and that there had been a buildup of debris behind the dish washing machine. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services
- Potential for harm · Dcited before2025-01-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a clinical records review and staff interview, it was determined that the facility failed to ensure that the wound care order was consistently followed for one of the three residents reviewed (Resident CL1). Findings include: A review of Resident CL1's diagnosis list includes Cerebrovascular Disease (an interruption in the flow of blood to cells in the brain) and Dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life). A review of the physician's wound consult dated November 11, 2024, revealed Resident CL1 had a worsening Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) to the right gluteus (buttock) measuring 10.0 x 9.0 x 0.3 cm. with 40% slough (A non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture that may be adherent to the base of the wound or present in clumps throughout the wound bed) and 50% eschar ( Is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
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 the facility's policy, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for ten of ten residents reviewed (Residents 2, 21, 24, 28, 66, 70, 78, 123, 161, 170). Findings include: A review of the facility's policy titled Enhanced Barrier Precautions (EBP), dated August 2022, revealed EBP's employees targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. EBP's are indicated for residents with wounds and indwelling medical devices regardless of MDRO (Multi Resistance Drug Organisms) colonization. Communication related to EBP precautions will be via signage, [NAME], or assignment sheets. PPE…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-15 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 facility policy, clinical record review, and staff interview, it was determined the facility failed to monitor weights and notify the physician of significant weight changes for six of 10 residents reviewed for nutrition (Residents 2, 6, 43, 161, 173, and 174). Findings include: Review of facility policy, Weight Assessment and Intervention, dated March 2019, indicated that any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation, if the weight is verified, nursing will notify the Physician and Dietitian. Further review of the policy indicated that The Dietitian and /or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate. Negative trends will be evaluated for whether or not the criteria for significant weight change has been met. Review of Resident 2's Weight Summary revealed Resident 2 weighed 217 pounds on October 5, 2024. Further review of Resident 2's Weight Summary revealed Resident 2 weighed 184 pounds on November 4, 2024.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, and staff interviews, it was determined that the facility failed to properly store frozen food in the main kitchen, and properly serve meals on one of five units observed (Rehab unit). Findings include: An observation of the walk-in freezer in the main kitchen was conducted on November 12, 2025, at 9:38 a.m., in the presence of the Assistant Food Service Director Employee E3. The observation revealed the following: Three boxes of frozen cookie dough in plastic bags, all were opened and unsealed; Unsealed frozen potatoes in a plastic bag; Unsealed frozen hamburger patties in a plastic bag; Unsealed frozen carrots in a plastic bag; and two plastic bags of chopped frozen chicken meat, both were opened and unsealed. An interview with Employee E3 conducted on November 12, 2024, confirmed that frozen food in a plastic bag should have been re-sealed after use. An observation of the meal pass was conducted on November 12, 2024, at 12:56 p.m., in the front hall Rehab Unit. The meal tray observation revealed peaches placed on a small bowl were uncovered. Apple juice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-15 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 observation, review of clinical records, and staff interviews, it was determined that the facility failed to ensure assessments accurately reflected the resident's status for three of the 35 residents reviewed (Residents 2, 67, and 123). Findings include: Review of Resident 2's Quarterly Minimum Data Set (MDS - A standardized assessment tool that measures health status in long-term care residents) dated September 10, 2024 revealed Resident 2 had an indwelling urinary catheter (a thin, flexible tube that drains urine from the bladder into a bag outside the body). Review of Resident 2's clinical record failed to reveal evidence of an indwelling urinary catheter. Interview with Licensed Employee E7 on November 15, 2024 at 11:00 confirmed Resident 2 did not have a urinary catheter and also confirmed Resident 2's Quarterly MDS dated [DATE] did not accurately reflect Resident 2's status and was completed incorrectly. A review of Resident 67's Quarterly Minimum Data Set, dated [DATE], revealed resident was 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.
- Potential for harm · D2024-11-15 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 ensure a baseline care plan for pressure ulcers was developed timely for one of seven residents reviewed (Resident 85). Findings include: A review of Resident 85's clinical records revealed resident was admitted to the facility on [DATE], with a right heel Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) measuring 3.8 x 3.2 x 0.2 cm. Clinical records review revealed Resident 85's pressure ulcer baseline care plan was not developed until July 2, 2024, a week after a resident was admitted and assessed with the presence of an unstageable pressure ulcer to the right heel. An interview conducted with the Director of Nursing (DON) on November 15, 2024, at 11:00 a.m., confirmed that Resident 85's baseline care plan for unstageable pressure ulcers was not developed until a week after it was identified. The facility failed to ensure Resident 85's unstageable pressure ulcer baseline care plan 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.
Show the remaining 21 citations
- Potential for harm · Dcited before2024-11-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon clinical record review, it was determined the facility failed to develop comprehensive care plans for a foley catheter and a wound vac for two of eighteen residents reviewed (Resident 78 and Resident 123) . Findings include: Review of Resident 78's diagnosis list revealed diagnoses including a history of prostate cancer and an enlarged prostate (gland in men encompasing the urethra when enlarged can restrict the flow of urine from the bladder out of the body). Review of Resident 78's clinical record revealed Resident 78 had a urinary catheter (a thin, flexible tube that drains urine from the bladder into a bag outside the body). Further review of Resident 78's clinical record failed to reveal evidence of a care plan for the urinary catheter. Interview with the Nursing Home Administrator on November 15, 2024 at 10:00 a.m. confirmed that Resident 78 did not have a comprehensive care plan for the foley catheter. A review of Resident 123's physician order dated October 3, 2024, revealed an order for a Wound vac (A device that uses negative pressure to help wounds heal) to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the facility's policy, observation, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician of a change in condition and follow a medication order for two of 35 residents reviewed (Residents 67 and 345). Findings include: A review of the facility's policy titled Weight Assessment and Intervention, dated March 2019, revealed any weight change of five pounds or more since the last weight assessment will be retaken for confirmation. Nurses will notify the Physician and dietitian. A review of Resident 67's diagnosis list includes Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain) and Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). An observation conducted on November 12, 2024, at 1:50 p.m., revealed Resident 67 was lying in bed, the left arm was observed swollen from the hands to the upper arm. An interview conducted with Resident 67 revealed left arm had been swollen but was unsure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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's policy, clinical record review and staff interview it was determined the facility failed to assess, monitor and treat pressure ulcers for two of eight residents reviewed. (Residents 82 and 106) Findings Include: Review of the facility's policy titled Skin and Wound Management System, undated, revealed Residents identified with skin impairments will have appropriate interventions, treatment, and services implemented to promote healing and impede infection. Wound location, characteristics, and a physician's order for treatment are documented in the medical record. Review of Resident 82's weekly skin review dated August 21, 2023 revealed the resident had a wound on the right heel that was pending treatment. Further review of the clinical record revealed there was no other documentation of this wound or notification to the physician of this new wound. Review of Resident 82's progress notes revealed a skin and wound note by the wound CRNP, dated September 7, 2023 at 8:53 a.m. which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 facility policy, observation, interview, and clinical record review, it was determined that the facility failed to ensure residents were free of accident hazards for three of 35 residents reviewed (Residents 12, 77, and 98) and failed to ensure residents had appropriate interventions in place to prevent falls for one of 35 residents reviewed (Resident 90). Findings include: Review of facility policy, Medication Administration - General Guidelines, undated, revealed that the resident is always observed after administration to ensure that the dose was completely ingested. Additionally, residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of Resident 12's nursing progress note of May 14, 2023, revealed that When this nurse went in to give morning meds[medications] she found cup full of pills in garbage at residents bedside. When resident was asked when were they from she responded from last night. I reinforced with resident the need to take…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to notify the provider of a resident change in condition in a timely manner for two of 35 residents reviewed (Residents 28 and 45). Findings include: Review of Resident 28's clinical record revealed a diagnosis of Type 1 Diabetes (insulin dependent). Review of Resident 28's November 2023 physician's orders revealed an order dated April 3, 2023, for Glucagon HCl Injection Solution Reconstituted 1 MG subcutaneously every 15 minutes as needed for as need it related to blood sugar bellow 70 and patient unresponsive turn on side, administer injection. Check BS every 15 minutes until BS reaches 70, offer a protein snack if PT responsive, call DR if nonresponsive. Review of the clinical record revealed a nursing note dated November 26, 2023, at 6:00 p.m. Resident 28 was found not responding and snoring heavily. Blood Sugar 42. IM Glucagon given. After 15 minutes, BS 62 but resident continues to not respond. Second dose of IM Glucagon given. After 15 minutes, BS 94, Resident w/ opened eyes but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, interviews with residents, review of facility documentation, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property to the appropriate State agency for one of 35 residents reviewed (Resident 91). Findings include: Review of facility policy, Abuse Policy, revised January 2020 revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and or designee. Interview with Resident 91 on December 19, 2023, at 9:03 a.m. revealed that she had reported $300 dollars missing approximately six months ago. Review of facility concern form completed June 9, 2023, revealed that Resident 91 had reported missing money and an investigation had been completed. Interview with the Nursing Home Administrator on December 21, 2023, at 12:30 p.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — the official record, unedited, may be distressing
Based on a review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 28 residents reviewed (Resident 73). Findings include: Review of Resident 73's admission orders of September 12, 2023, included an order for hemodialysis (process to filter wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work) every Tuesday, Thursday, and Saturday. Further review of the clinical record revealed no care plan regarding dialysis. Interview with the Nursing Home Administrator on December 21, 2023, at 10:30 a.m. confirmed that there was no care plan in place to address the hemodialysis. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/3/23 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/3/23
- Potential for harm · D2023-12-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and clinical record review, it was determined that the facility failed to ensure that residents were provided with consistent, adequate catheter care for one of five residents reviewed for catheters (Resident 79). Interview with Resident 79 on December 19, 2023, at approximately 12:50 p.m. revealed the resident had an indwelling foley catheter (a thin, flexible tube placed in the bladder through the urethra to drain urine). Resident 79 revealed staff were not routinely providing care to the catheter to prevent urinary tract infections (UTIs). Review of Resident 79's clinical record failed to review physician orders or nursing interventions on the care plan addressing the resident's catheter care. Interview with the Nursing Home Administrator on December 21, 2023, at approximately 12:35 p.m. confirmed there was no documented evidence that Resident 79 was receiving catheter care. 28 Pa Code 211.12(d)(5) Nursing services
- Potential for harm · D2023-12-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview it was determined the facility failed to provide pharmacy services for one of 40 residents reviewed. (Resident 82) Findings Include: Review of Resident 82's physician orders revealed an order for Oxycodone-acetaminophen (combination Narcotic pain reliever and Tylenol) oral tablet 7.5-325 give every six hours for pain dated August 21, 2023. Review of Resident 82's Medication Administration Record (MAR) for October 2023 revealed the resident did not receive all four doses on October 14, 2023, the midnight dose of October 15, 2023 or three doses on October 18, 2023 for a total of eight doses. Review of Resident 82's progress notes revealed a nursing entry dated October 14, 2023 at 4:44 a.m. revealed Resident ran out of his Percocet 7.5-325 mg po tab and missed last evening's 1800 (6 p.m.) dose and midnight 0000 dose. Supervisor notified. Medication dose is not available in facility's emergency kit but have Percocet 5-325 mg dose available. PRN Tylenol given this shift while waiting for Pharmacy to deliver med but med did not arrive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 clinical record review and staff interview it was determined the facility failed to monitor side effects for resident on antipsychotic medications for one of 5 residents reviewed. (Resident 6). Findings Include: Review of facility policy and procedure titled Antipsychotic Medication Use, revised on January 2016, revealed Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation Cardiovascular: orthostatic hypotension, arrythmias (abnormal heart beats) Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or Neurologic: akathisia (uneasiness), dystonia (muscle contraction), extrapyramidal effects (involuntary movements), akinesia (inability to move); or traditive dyskinesia, (muscle movements cause by medications), stroke, or TIA. Review of Resident 6 care plan revealed a care plan with a focus on Hazel uses psychotropic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 the facility's policy, clinical records pharmacy documentation review, and staff interviews, it was determined that the facility failed to ensure anti-seizure medication was administered as ordered by the physician for one of 35 residents reviewed (Resident 109). Findings include: Rview of the facility's policy titled Medication Administration-General Guideline; undated revealed medications are administered by written orders of the attending physician. Clinical records review revealed Resident 109 was admitted to the facility on [DATE], with a diagnosis of Cerebral Infarction (A condition caused by a lack of blood flow to part of your brain), Traumatic Brain Injury (TBI- An injury that affects how the brain works), and Epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures). Nursing progress notes revealed resident arrived in the facility on September 14, 2023, around 10:00 a.m., and orders were verified with the Nurse Practitioner (NP), Employee E4 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.
- Potential for harm · E2023-12-21 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interview it was determined the facility failed to obtain informed consent prior to laboratory studies for five of 40 residents reviewed (Residents 6, 79, 90, 100, and 107). Findings include: Review of Resident 6's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident is severely cognitively impaired. Review of Resident 6's clinical record revealed an informed consent for pharmacogenomics testing. There was a stamp by the signature line stating patient incapable of signing , gave verbal consent to be screened for pharmacogenomic testing through gene ID lab for medication management with a date written of September 20, 2023 and a signature. Review of Resident 79's Significant Change MDS dated [DATE], revealed a BIMS of 15, indicating the resident has no cognitive impairment. Interview with Resident 79 on December 19, 2023, at approximately 12:40 p.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 documentation, observations and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing. Findings include: Review of facility's Dish Machine Temperature Log for February 2023 revealed the wash temperature must be at least 150 degrees and the final rinse temperature at least 180 degrees. Observation of the dish machine on February 28, 2023, at 9:53 a.m. with Employee E6 revealed a rinse temperature of 152 degrees. Additional observation on March 1, 2023, at 9:39 a.m. revealed a rinse temperature of 171 degrees. Interview with Employee E6 at the time of the observation confirmed that the temperatures were not reaching acceptable temperatures. Employee E6 indicated that the service company had been in and indicated that a part had to be ordered. Review of the Dish Machine Temperature Log for February 2023 revealed that the recorded final rinse temperature did not reach 180 degrees on 76 of 78 occasions. 483.60(i)(2) Food Procurement, Store/Prepare/Serve - Sanitary Previously cited 1/28/22 28…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-03 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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 upon a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that any irregularities were acted upon by a physician for three of five residents reviewed (Residents 65, 66, and 110). Findings include: Review of facility policy Consultant Pharmacist Report revealed that the consultant pharmacist's observations and recommendations regarding residents' medication therapy are communicated to those with authority and/or responsibility to implement the recommendations, and responded to in an appropriate and timely fashion. Review of Resident 65's clinical record revealed that Medication Record Reviews (MRRs) completed on December 28, 2022 and January 10, 2023 indicated recommendations were made and to review the report. Review of Resident 65's Note to Attending Physician/Prescriber dated December 28, 2022 and January 10, 2023 revealed the consultant pharmacist was recommending gradual dose reductions and to review a list of unnecessary medications for elimination. Further review of Resident 65's pharmacist…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-03 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 upon interview and clinical record review, it was determined the facility failed to have resident participation in care plan meeting or develop a plan of care for one of 32 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed Resident 2 was admitted to the facility on [DATE]. Interview conducted with Resident 2 on February 28, 2023 at 10:00 a.m. revealed Resident 2 indicating displeasure being a resident in the facility and unaware of her plan of care. Resident 2 indicated she had not spoken to a social worker or had not been advised of current status or plan for discharge. Review of Resident 2's Multidisciplinary Care Conference note dated February 7, 2023 revealed Resident 2 was in attendance at the care plan meeting. Interview with Employee E5 on March 1, 2023 at 11:00 a.m. indicated that Employee E5 was unsure if Resident 2 attended the care conference meeting on February 7, 2023 and the attendance sheet for the meeting did not contain Resident 2'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.
- Potential for harm · D2023-03-03 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 upon review of facility policy and procedure, interviews and clinical record review, it was determined the facility failed to have resident designate their own code status and failed to allow resident to participate in their own care treatment and discharge planning and failed to obtain appropriate signatures for POLST (Physician Orders for Life Sustaining Treatment) for one of 32 residents reviewed (Resident 2). Findings include: Review of facility policy and procedure titled Advance Directives revealed Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Further review of this policy and procedure revealed prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Further review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record reviews, resident and staff interviews, it was determined the facility failed to ensure physician orders were followed for three of 32 residents reviewed (Resident 12, 82, and 356) and failed to adequately and timely assess complete wound assessments for one of 32 residents reviewed (Resident 107). Findings include: Review of Resident 12's diagnosis list revealed left ankle and foot Osteomyelitis (Infection to the bone), and Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Interview with Resident 12 conducted on March 2, 2023, at 11:00 a.m., revealed that her/his blood sugar had been unstable, sometimes very high and sometimes low. Review of Resident 12's February 2023 Medication Administration Record (MAR) revealed Resident 12's blood sugar result ranges from a result of 80-508 mg/dl. Review of Resident 12's physician order dated February 17, 2023, revealed Insulin Glargine (long-acting insulin) 100 unit/ml. Inject 24 units subcutaneously (insertion of medications beneath the skin either by injection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's policy, observation, clinical records review, and staff interviews, it was determined that the facility failed to follow the recommended treatment of the wound care doctor for one of the five residents reviewed (Resident 150). Findings include: Review of Resident 150's clinical record and admission assessment dated [DATE], revealed the resident was admitted with multiple wounds including an opened left hip wound measuring 7.5 x 4.5 x 0.1 cm [centimeter]in size. Review of Resident 150's Treatment Administration Record (TAR) revealed that the left hip wound was treated with skin prep wipes two times daily. Review of wound care consult dated February 7, 2023, revealed Resident 150's multiple wounds were present upon admission, the left hip wound was identified as an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) with a measurement of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 record and staff interview, it was determined that the facility failed to appropriately monitor and assess a resident weight status for two of six residents reviewed (Resident 127, and 150). Findings include: Review of Resident 127's clinical record revealed the following weights: 2/17/2023- 138.8 lbs, 1/12/2023-151.8 lbs, 12/1/2022-165.6 lbs. Between December 1, 2022, and February 17, 2023, Resident 127 lost 16.18% of his body weight. Review of Facilities weight loss policy indicated a 10% weight loss within 6 months is considered significant. Review of Resident 127's clinical record revealed Resident 127 was diagnosed with Covid-19 on December 26, 2022. Further review of Resident 127's clinical record revealed a Dietary Note dated January 13, 2023, stating Resident 127 has experienced significant weight loss, PO (by mouth) intake expected to return to normal post-covid. No new nutrition recommendations at this time. Additional review of clinical record revealed a Dietary note dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and staff interviews, it was determined that the facility failed to ensure infection control and prevention were maintained during wound care treatment for one of two residents observed (Resident 150). Findings include: Obsevation of wound treatment of Resident 150 was conducted on March 2, 2023, at 11:08 a.m., with licensed nurse Employee E7. The wound care supplies were observed on the resident's tray table, with personal belongings on the same table. After washing their hands with soap and water, Employee E7 put on a pair of clean gloves, took the medication ointment tube then squeezed the content into the medication cup. Wearing the same gloves, Employee E7 opened a sterile package of Calcium Alginate, took a scissor from her/his pocket then placed it on the tray table without cleaning it, pulled the light string to open the overhead light, opened the resident's incontinent brief, then repositioned the resident on his/her side. The nurse removed the resident's old dressing from the left hip, then threw it in the garbage. Without performing hand hygiene 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.
- No harm found · Bcited before2023-12-21 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 ensure that assessments accurately reflected the resident's status for three of 40 residents reviewed (Residents 56, 73, and 174). Findings include: Review of Resident 56's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) assessment of November 16, 2023, section H0100, bowel and bladder appliance, indicated that the resident had an indwelling catheter (tube that drains urine from the bladder into a bag outside the body). Further review of the clinical record revealed no indication that the resident had a catheter. Interview with licensed staff, E5, on December 20, 2023, at 1:00 p.m. confirmed that Resident 56 did not have a catheter and the MDS was coded incorrectly. Review of Resident 73's admission orders of September 12, 2023, included an order for hemodialysis (process to filter wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work) every…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$9,516 in federal fines across 1 penalty.
- $9,516 — penalty dated 2026-01-02
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SPACEBAR OPCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2021 |
| AI ELEMENTS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 33% | since 11/01/2021 |
| STRAWBERRY HILL HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 33% | since 02/25/2022 |
| TILDE PROPCO HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 33% | since 01/01/2023 |
| CLINICAL CONSULTING SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/20/2025 |
| PRIORITY CARE GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2021 |
| SUMMATION FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/20/2025 |
| FISHER YOHN, CARLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/07/2025 |
| PECK, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/20/2025 |
| 2829 LITITZ PROPCO LLC | Organization | ADP OF THE SNF | — | since 11/01/2021 |
CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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.
About 86% 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 $4.6M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395205. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-15, 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.