Laureldale Skilled Nursing And Rehabilitation Cent
2125 Elizabeth Avenue, Laureldale, PA 19605 · For profit - Corporation · 198 certified beds · (610) 921-9292 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
- 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
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,036 in federal fines (most recent 2024-08-16)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
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 | 22.2% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.2% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.7% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 67.0% | 10.8% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.0% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.8% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.7% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.0% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 44.8% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 28.4% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 3.7% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.52 | 1.62 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 1.18 | 1.80 | 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.
46.0% 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 156 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.6% 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 82 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% 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 | 46.0%CMS range 38.9–55.0 | 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 | 10.0%CMS range 7.2–13.2 | 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 | 47.6% | 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 | 47.6% | 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 | 46.3% | 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 | 98.1% | 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 | 92.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 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 | 7.6%CMS range 5.2–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 198 beds and averages 170.0 residents a day — about 86% occupied, or roughly 28 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.550 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 2.99 hrs/resident/day on weekends vs 3.39 on weekdays — 12% thinner on weekends. RN hours go from 0.65 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2024-08-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to keep one of three sampled residents free from neglect, which resulted in actual harm of a head injury. (Resident 1) Findings include. Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension (high blood pressure), history of transient ischemic attacks (temporary interruptions of blood supply to the brain), atherosclerotic cardiovascular disease (a condition of increased plaque in the arteries of the heart, potentially causing heart attacks), and chronic respiratory failure. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated [DATE], indicated that the resident had a history of falls and required maximum assistance to use the toilet. The care plan identified that Resident 1 was at risk for falls and required assistance with activities of daily living (basic self-care tasks such as personal hygiene…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-08-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents related to falls for one of three sampled residents which resulted in actual harm of a head injury. (Resident 1) Findings include. Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension (high blood pressure), history of transient ischemic attacks (temporary interruptions of blood supply to the brain), atherosclerotic cardiovascular disease (a condition of increased plaque in the arteries of the heart, potentially causing heart attacks), and chronic respiratory failure. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated [DATE], indicated that the resident had a history of falls and required maximum assistance to use the toilet. The care plan identified that Resident 1 was at risk for falls and required assistance with activities…
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 before2026-06-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the kitchen.Findings include: Observations during the kitchen tour on June 7, 2026, at 9:30 a.m., revealed the following: In the walk-in refrigerator, there was a container of prepared meatballs labeled with a use by date of June 4, 2026. There were four, two-pound packages of smoked deli turkey breast labeled use or freeze by May 30, 2026. In the food preparation coolers, there was a gallon of chocolate milk without a lid, a Chef's salad without a name or date, and a container of eggs for room [ROOM NUMBER]-B with no date. There was an uncovered container with garbage near a clean rack of pitchers. On the second shelf of a wire rack, there was an undated container of cereal. In the dry storage area, there was a box of tea bags in an open plastic bag. During an interview on June 7, 2026, at 12:10 p.m., the Dietary Director confirmed that the items observed…
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 before2026-06-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 observation and staff interview, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on two of four nursing units. (Second and Third Floors)Findings include: Observation on June 7, 2026, from 11:03 a.m. through 1:53 p.m., June 8, 2026, from 11:00 a.m. through 2:36 p.m., and June 9, 2026, from 9:15 a.m. 11:21 a.m. revealed the following: On the second-floor unit, there was a pervasive urine odor in the corridor. In the shower room on unit two, the left shower stall had debris on the floor and there was a wet washcloth tied around the hose of the shower sprayer. There was rust on the metal ceiling tile separators in the left shower. There was peeling wallpaper above the bathroom door, and a brown stain on the wallpaper behind the door. The screws holding the metal toilet paper holder in the wall were loose and it was hanging down, and there was a rusty outlet cover near the sink. In room [ROOM NUMBER], there was a strong, pervasive, odor…
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 before2026-06-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for three of 33 sampled residents. (Residents 1, 73, 149)Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure, dementia, and wasting muscles. Review of the Care Area Assessment (CAA) section of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 1 was to have a care plan developed for fall prevention. Review of the clinical record revealed no evidence that a care plan was developed for interventions to prevent falls. Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses that included cellulitis of left lower limb, pressure ulcer of right ankle, and pressure induced deep tissue damage. On May 21, 2026, the physician ordered for staff to provide wound treatments 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.
- Potential for harm · Dcited before2026-06-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (grooming and hygiene) for two of 33 sampled residents. (Residents 8, 10)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included hemiplegia and hemiparesis following a right-side dominant stroke, type 2 diabetes mellitus, polyneuropathy (damage to multiple peripheral nerves throughout the body resulting in symmetrical numbness), and need for assistance with personal care. A Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 8 and was dependent on staff for assistance with activities of daily living (ADLs), including personal hygiene (including daily skin checks), bathing, and dressing. Review of the care plan revealed that staff were to assist the resident with hygiene, bathing and dressing, and his preference was to be awake daily between 7:00 a.m. and 9:00…
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 before2026-06-10 · 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
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 implement physicians' orders for three of 33 sampled residents. (Residents 3, 33, 87) Findings include:Clinical record review revealed that Resident 3 had diagnoses that included severe chronic kidney disease and heart failure. A physician's order dated March 9, 2026, directed staff to weigh Resident 3 every seven days and call the cardiologist if weight gain was more than three pounds. Review of Resident 3's 2026 Medication Administration Record (MAR) for April, May, and June, revealed no evidence that weekly weight checks were completed on five of seven occasions from April 14, 2026, through June 5, 2026. Clinical record review revealed that Resident 33 had diagnoses that included hypotension (low blood pressure) and chronic kidney disease. A physician's order dated April 14, 2026, directed staff to administer 10 milligrams (mg) of a blood pressure medication (midodrine) three times daily. The physician ordered…
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 · D2026-06-10 · 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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide interventions to prevent new or worsened pressure ulcers for one of five sampled residents with wounds. (Resident 3)Findings include: Review of the facility policy entitled, Skin Integrity and Wound Management, last reviewed March 1, 2026, revealed that a licensed nurse was to perform and document skin inspections on residents weekly and with any significant change of condition. Clinical record review revealed that Resident 3 had diagnoses that included a muscle disorder and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 3 was cognitively impaired, was dependent on assistance from staff for activities of daily living, and had a stage three pressure wound on her left heel. Review of the care plan revealed the resident had actual skin breakdown on her left heel, was at risk for further skin impairment, and included an intervention…
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 before2026-06-10 · 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess the nutritional status for two of 33 sampled residents. (Residents 2, 80) Findings include: Review of the facility policy entitled, Weights and Heights, last reviewed March 1, 2026, revealed that residents would be weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter, and staff would enter the weight into the electronic health record.Clinical record review revealed that Resident 2 was readmitted to the facility on [DATE], with diagnoses that included diabetes, gastrostomy malfunction, and dysphagia (difficulty swallowing). On May 12, 2026, the physician ordered for staff to obtain a weight every Monday for four weeks then monthly on the first of the month. Review of Resident 2's care plan revealed the resident was at risk for a nutritional problem and dehydration with an intervention to monitor the resident's weight per…
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 · D2026-06-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were properly stored per facility policy on one of four nursing units. (Third Floor) Findings include: Review of the facility policy entitled, Medication Administration, last reviewed March 1, 2026, revealed medications were to be administered at the time they were prepared. Observations during the medication pass on June 7, 2026, at 9:35 a.m., revealed that two uncovered medication cups labeled with black marker in a medication cart on the third floor contained two residents' medications. In an interview at that time, Licensed Practical Nurse (LPN) 1 confirmed she had poured the medications into medication cups earlier but did not administer them at that time. In an interview on June 9, 2026, at 1:47 p.m., the Director of Nursing confirmed the medications should not have been stored in cups in the medication cart prior to administration. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
- Potential for harm · D2026-06-10 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide (NA) received 12 hours of in-service training annually, including training for dementia management, resident abuse prevention, and identified performance weaknesses for one of five nurse aides reviewed. (NA 1)Findings include:Review of NA 1's personnel record revealed that they had been employed by the facility since November 2, 2015.Review of facility training records dated July 1, 2024, to June 8, 2026, revealed that NA 1 completed only nine hours and 29 minutes of in-service education.In an interview on June 9, 2026, at 10:39 a.m., the Administrator confirmed that NA 1 had not completed the required annual in-service training.28 Pa. Code 201.19(7) Personnel policies and procedures.28 Pa. Code 201.20(a)(6)(d) Staff development.
- Potential for harm · Dcited before2025-07-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of three nursing units. (Second and Third floors)Findings include: Observations on July 15, 2025, from 7:30 a.m. through 2:30 p.m. revealed the following environmental issues: Roof shingles were missing over the Heritage Wing of the first floor. Ceiling tiles and wallpaper were peeling in bathroom of room [ROOM NUMBER]. Ceiling tiles were peeling in bathroom of room [ROOM NUMBER]. The wallpaper below the sink and above the window was damaged in room [ROOM NUMBER]. A wall was damaged in the bathroom of room [ROOM NUMBER]. Wallpaper was peeling behind the bed in room [ROOM NUMBER]. The wall near the door of the second floor lounge was damaged. Ceiling tiles in the second floor dining room near the storage door were damaged. Wallpaper was peeling in the activity room by the office door. Ceiling tiles in the second floor in the lounge with the vending machines were damaged. The vent hose for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2025-07-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
Based on observation, clinical record review, and staff and resident interviews, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for four of 33 sampled residents. (Residents 14, 15, 55, and 62)Findings include: Clinical record review revealed that Resident 14 had diagnoses that included: paraplegia and congestive heart failure. Review of the care plan dated May 30, 2025, revealed that the resident required assistance with activities of daily living (ADLs) including grooming and bathing. On July 15, 2025, at 9:09 a.m., the resident was observed in bed. His fingernails were long and dirty. He was unshaven. The resident stated that his fingernails needed to be cut, and he would like a shave. On July 16, 2025, at 11:23 a.m., and on July 17, 2025, at 10:47 a.m. the resident was observed in bed. His fingernails remained long and dirty. He was unshaven.Clinical record review revealed that Resident 15 had diagnoses that included: dementia and polyneuropathy (nerve damage resulting in numbness in his extremities). Review of the care…
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 before2025-07-18 · 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 review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 33 sampled residents. (Residents 47 and 103)Findings include: Clinical record review revealed that Resident 47 had diagnoses that included Alzheimer's disease and hypertension (high blood pressure). A physician's order dated July 20, 2024, directed staff to administer a medication (Bisoprolol Fumarate) three times a day for hypotension. The medication was to be held if the resident's systolic blood pressure (SBP) was lower than 90 millimeters of mercury (mm/Hg) or if the resident's heart rate was less than 60 beats per minute. Review of Resident 47's medication administration records (MARs) revealed that staff administered the medication three times in April 2025, twice in May 2025, four times in June 2025, and three times in July 2025 when the resident's heart rate was less than 60 beats per minute.Clinical record review revealed that Resident 103 had diagnoses that included epilepsy, dementia, and hypertension (high blood pressure). A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator/Abuse Prevention Coordinator of the facility for one of six sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed March 26, 2025, revealed that all incidents and allegations of abuse, including injuries of unknown origin, were to be reported immediately to the administrator or designee. Clinical record review revealed that Resident 1 had diagnoses that included dementia and ventricular tachycardia (abnormal heart rhythm that occurs when the lower chamber of the heart beats too fast). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required staff assistance with personal hygiene, and was dependent on staff for transfers. Review of facility witness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-19 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to protect one of eight sampled residents (Resident 2) from sexual abuse by another resident (Resident 1). Findings include: Clinical record review revealed that Resident 2 had diagnoses that included dementia and depression. According to her Minimum Data Set (MDS) assessment, dated February 3, 2025, she was cognitively impaired, had difficulty communicating, and was dependent on staff for mobility. Clinical record review revealed that Resident 1 had diagnoses that included cancer and dementia. According to the MDS assessment, dated August 12, 2024, the resident had periods of depressed mood and was able to move about the facility independently. In an interview on February 19, 2025, at 11:53 a.m., the nurse practitioner (NP 1) stated that Resident 1's room was changed on June 7, 2023, due to sexually inappropriate behavior with a cognitively impaired female resident, and as a result he was monitored by the psychiatrist for concerns including sexually…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-19 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 readmit a resident after a transfer to the hospital for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included cancer and dementia. On February 9, 2025, at 10:34 p.m., a nurse noted that the resident was observed groping another resident and that he became combative with staff. On February 10, 2025, at 2:37 p.m., a nurse noted that the resident was sent to the hospital for an evaluation from a psychiatrist. In an interview on February 19, 2025, at 1:22 p.m., SW 1 (the hospital social worker) stated that the resident received the psychiatric evaluation and was deemed safe to return to the facility. She further stated that the resident remained in the facility and that the facility instructed the hospital that they would not be accepting the resident back. In an interview on February 19, 2025, at 9:30 a.m., the Administrator confirmed that the resident was discharged to the hospital and was not permitted…
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 · D2024-08-16 · 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 — the official record, unedited, may be distressing
Based on clinical record review, facility documentation reivew, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition and a fall for one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension, history of transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure. On August 6, 2024, at 3:15 p.m., a nurse noted that the resident fell after using the toilet. According to the facility investigation into the fall, the resident's responsible party was not notified of the fall until the following day at 3:30 p.m. In an interview on August 16, 2024, the Director of Nursing stated that staff was to notify the responsible immediately after a fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
- Potential for harm · Ecited before2024-06-27 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during the environmental tour on June 25, 2024, at 8:30 a.m., revealed three pipes covered in dust lying on the floor near the ice machine. There were two dirty bowls behind the ice machine, and water was observed draining from the ice machine onto the floor underneath and around the ice machine, creating areas of standing water. In the dish room, there was a vent with various areas of peeling paint. 28 Pa. Code 201.18(e)(2.1) Management.
- Potential for harm · Dcited before2024-06-27 · 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 review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 35 sampled residents. (Residents 135, 151) Findings include: Clinical record review revealed that Resident 135 had diagnoses that included history of a stroke and high blood pressure. On June 1, 2024, a physician's order directed staff to administer a medication (metoprolol tartrate) two times a day to treat the resident's high blood pressure and heart rate. Staff was not to give the medication if the resident had a systolic (top number of a blood pressure reading) blood pressure below 110 millimeters of mercury (mmHg) or if the heart rate was less than 50 beats per minute. A review of the June 2024, Medication Administration Record (MAR) revealed that staff administered the medication over 43 times without checking that the blood pressure and heart rate were above the hold parameters. Clinical record review revealed that Resident 151 had diagnoses that included sepsis, kidney failure, and heart failure. On May 31, 2024, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 resident and staff interview, it was determined that the facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility on a consistent basis for three of 35 sampled residents. (Residents 4, 31, 83) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included dementia, congestive heart failure, and hemiplegia (one sided paralysis or weakness). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and required staff assistance for activities of daily living. Review of Resident 4's current care plan revealed that she was at risk for loss of range of motion due to her physical limitations and that staff was to provide a restorative nursing program for passive range of motion exercises to her legs with morning and evening care. There was no documented evidence to support that staff was completing passive range of motion…
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 before2024-06-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, observation, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent accidents/hazards on two of four nursing units. (Second Floor Unit and Third Floor Unit) In addition, it was determined that the facility failed to thoroughly investigate a fall and provide appropriate interventions for one of six sampled residents identified at risk for falls. (Resident 56) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included gastro-esophageal reflux disease, dementia, and spinal stenosis. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment. On January 18, 2024, the physician ordered a dysphagia mechanically altered texture diet. Review of Resident 9's care plan revealed she had a self-care deficit with an intervention for staff to provide meal support. Observations on June 26, 2024, from 12:38 p.m. through 12:50…
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 · D2024-06-27 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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, observation, and resident interview, it was determined that the facility failed to accomodate each resident's preference at meal times for two of 35 sampled residents. (Residents 21, 130) Findings include: Clinical record review revealed that Resident 21 had diagnoses that included diabetes, gastro-esophageal reflux disease (GERD), and problems with the intestines. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was alert and oriented. Review of Resident 21's care plan revealed she had potential for a nutritional problem related to diabetes, GERD, and intestinal issues. Observation on June 26, 2024, from 12:40 p.m. through 12:55 p.m., revealed Resident 21 with her lunch tray. Resident 21's meal ticket stated she was not to have gravy on any part of her meal. Resident 21 was observed with three ounces of roast pork that was heavily coated with a dark brown gravy. In an interview on June 26, 2024, at 12:45 p.m., Resident 21 stated she did not…
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 before2024-03-13 · 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
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 develop a comprehensive care plan to meet a resident's needs identified in the comprehensive assessment for one of seven residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included diabetes and an altered mental state. The Minimum Data Set Care Area Assessment summary dated January 20, 2024, noted that the resident was at risk for impaired nutrition and that it was to be addressed in the care plan. There was no evidence that interventions to address Resident 1's nutritional needs were included in the current care plan. In an interview on March 13, 2024, at 2:21 p.m., the Nursing Home Administrator confirmed that the identified care area was not addressed in the resident's care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
- Potential for harm · Dcited before2024-03-13 · 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to timely assess nutritional status for two of seven sampled residents. (Residents 1, 6) Findings include: Review of the facility policy entitled, Weights and Heights, dated August 1, 2023, revealed that residents were to be weighed upon admission and then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. Review of the facility policy entitled, Change in Condition dated August 1, 2023, revealed that a facility must immediately inform the resident, the physician, and responsible party (RP) of a significant change in the resident's physical status (deterioration in health). Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included diabetes and altered mental state. Review of the Minimum Data Set (MDS) assessment, dated February 7, 2024, revealed 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 before2024-01-03 · 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 review and staff interview, it was determined that the facility failed to failed to ensure that physician's orders were implemented for two of eight sampled residents. (Residents CL2, 7) Findings include: Clinical record review revealed that Resident CL2 had diagnoses that included venous insufficiency and diabetes. Review of Resident CL2's care plan revealed that he was at risk for alteration in skin integrity related to pressure. On December 14, 2023, the wound certified registered nurse practitioner documented that Resident CL2 had a deep tissue pressure injury to his left heel and ordered for staff to apply Betadine (antiseptic used to treat wounds) daily. There was no documented evidence that this treatment was implemented. In an interview on January 3, 2024, at 12:31 p.m., the Director of Nursing confirmed that the Betadine treatment was not provided to Resident CL2. Clinical record review revealed that Resident 7 had diagnoses that included sleep apnea and depression. Review of Resident 7's care plan revealed he was at risk for altered respiratory…
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 before2024-01-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility docmentation review, and staff interview, it was determined that the facility failed to ensure that safety interventions were in place to prevent falls for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dementia, congestive heart failure, and muscle weakness. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment and was dependent on staff assistance to roll left and right in bed. Review of the care plan revealed that two staff were to assist with all care. Review of facility documentation dated December 28, 2023, revealed that Resident 1 rolled out of bed during incontinence care while being assisted by one staff member. In an interview on January 3, 2024, at 1:16 p.m., the Administrator confirmed that the required number of two staff members was not used to provide incontinence care to the resident. 28 Pa. Code 211.12(d)(1)(5)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
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 residents were assisted with bathing in accordance with individual preferences for two of six sampled residents. (Resident 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included a fractured rib, heart disease, dementia and anxiety. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had minimal memory impairment and required assistance from staff with showering. A review of the care plan revealed that the resident had a deficit in Activities of Daily Living (ADL's) due to physicial limitations. There was an intervention for staff to assist him with showering and bathing as needed. Review of the nurse aide documentation for the last 30 days revealed that Resident 1 was scheduled to receive assistance with a shower/bathing on Mondays and Thursdays on the evening shift. There was no documented evidence that the resident had been…
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 · B2024-06-27 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 notify the resident's representative(s) of transfer and the reasons for the move in writing for nine of 12 sampled residents who were transferred to the hospital. (Residents 2, 4, 13, 14, 15, 18, 83, 130, 155) Findings include: Clinical record review revealed that Resident 2 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 4 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 13 was transferred and admitted to the hospital on [DATE], after a change in condition.…
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
$16,036 in federal fines across 2 penalties.
- $8,018 — penalty dated 2024-08-16
- $8,018 — penalty dated 2024-08-16
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 3.5 | -0.5 vs chain |
The other 183 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 183; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GENESIS PM PA OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/15/2022 |
| FC-GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2020 |
| GHC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| SUN HEALTHCARE GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 11/15/2022 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| DESARRO, GREGORY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
9 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 81% 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 $4.0M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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 395477. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, 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 →
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