Statesman Health & Rehabilitation Center
2629 Trenton Road, Levittown, PA 19056 · For profit - Limited Liability company · 101 certified beds · (215) 943-7777 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)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 19% 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 3 to 4 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 | 9.4% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.0% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 26.6% | 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 | 2.5% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.2% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.6% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.8% | 25.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 17.7% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.5% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.8% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 2.6% | 9.5% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† 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.
58.5% 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 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 88 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 58.5%CMS range 47.7–70.0 | 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 | 11.1%CMS range 7.6–14.6 | 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 | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 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 | 43.2% | 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 | 47.5% | 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 | 82.1% | 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 | 100.0% | 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 | 1.7% | 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 | 0.8% | 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 | 5.5%CMS range 3.0–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 101 beds and averages 98.7 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.25 hrs/resident/day on weekends vs 3.59 on weekdays — 9% thinner on weekends. RN hours go from 0.60 to 0.32 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%.
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.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · E2025-09-05 · tag F0575 — patternPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, resident interviews, and staff interviews it was determined that the facility failed to ensure required posting for the Department of Health were displayed at the facility. Findings Include: Observation on September 2, 2025 at 10:05 a.m. revealed the main lobby, A wing, B wing, and C wing did not have any postings or signage for the Department of Health. This was confirmed by the front desk receptionist Employee E7 at 10:09 a.m. An interview was held with the Nursing Home Administrator, Employee E1 at 10:10 a.m. The interview revealed that there was one spot outside of the lobby area where the name and phone number are posted and stated, it must have been taken down by one of the residents. Employee E1 confirmed that this is the only place where the Department of Health reporting phone number is posted in the facility. Review of the posting after is was placed back up revealed there was no information other than the phone number.28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(e) Management.
- Potential for harm · E2025-09-05 · 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 and staff interview, it was determined that the facility failed to maintain a safe and home-like environment for one of three nursing units observed. (C wing)Findings Include: On September 2, 2025, at 12:02 p.m., observation conducted on C wing of the bathroom of Resident R80's room, revealed that the covering of the heater/cooler- outlet- was not properly fixated to the heater/cooler- outlet and the rusted metal pieces were exposed around the base of the wall. The same observation was noted on September 3, 2025, at 10:01 a.m., on September 4, 2025, at 10:31 a.m., and on September 5, 2025, at 9:31 a.m.On September 2, 2025, at 12:22 p.m., observation made of the hallway in front of Resident R8's room revealed that the covering of the heater/cooler- outlet- was not properly fixated to the heater/cooler- outlet and the rusted metal pieces were exposed around the base of the wall. The same observation was noted on September 3, 2025, at 10:11 a.m.Interview and observations made with the Assistant Director of Nursing on September 5, 2025, at 9:47 a.m., confirmed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-05 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure residents received quality care related to incontinence care for and medication administration for three of twenty-one residents reviewed (R5, R57, R114) Findings include: Review of facility policy “Medication Administration/ Disposition”, revised September 2023, revealed medications should be administered in a safe and timely manner, and as prescribed. Facility staff involved in the administration of resident care will be knowledgeable of the policies and procedures regarding pharmacy services including medication administration. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician or the physician's designee. Clinical record review revealed Resident R5 was admitted to the facility on [DATE] with a diagnosis that included Rhabdomyolysis (muscles break down and release toxins into blood and kidneys),…
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 · E2025-09-05 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staff hours as required.Findings Include:On September 5, 2025 at 10:34 a.m. observations at the front lobby area revealed staffing was posted is a spot behind the front desk receptionist on the wall in a clear sleeve. Observation of the posting revealed the posting would be difficult to access for people with mobility issues due to the height of the posting and the position behind the receptionist desk. Employee E7 the front desk receptionist, was asked if this was the only placed that the staffing was posted and Employee E7 replied, I believe so. The form in the clear sleeve on the wall was from September 4, 2025 and the form was left blank without any of the staffing information filled in. The only portion of the form that filled it was the date, written in pencil. Further observation of three wings (A, B, C) revealed there was no other staffing posted throughout the building. On September 5, 2025 at t 10:37 a.m. an interview was held with the Assistant…
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 before2025-09-05 · 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 observations, clinical record review, review of facility policy and interviews with staff, it was determined that the facility did not ensure a care plan was developed for one of twenty-two residents reviewed. (Resident R57)Findings Include: Review of facility policy titled, Comprehensive Care Planning Policy with a revision date of March 20, 2025 states, Policy- An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. Further review of the policy revealed, Procedure- the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. These plans will be focused on resident choices and abilities with the intent of maintaining and improving resident functional abilities and quality of life. Interview held with Resident R57 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 · Ecited before2025-04-08 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, and interview with staff, it was determined that the facility failed to ensure that a rational was provided for the discontinuation of blood sugar monitoring for 6 of 6 residents reviewed who were insulin dependent (Resident R1, R2, R3, R4, R5, R6). Findings include: Interview with the Assistant Director of Nursing conducted on April 8, 2025, at approximately 12:00 p.m. revealed that the facility is discontinuing blood sugar check orders related to resident blood sugar trends and A1C blood test (blood test that provides an average of your blood sugar levels over the previous 2- 3 months). Continued interview revealed that there is no facility policy regarding discontinuing blood sugar checks for residents with diabetes diagnosis and receiving insulin. Interview with the Director of Nursing conducted on April 8, 2025, at approximately 1:00 p.m. revealed the facility is discontinuing blood sugar check orders related to resident blood sugar trends and A1C blood test. Further interview confirmed that there is no facility policy regarding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · 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 on staff and family interviews and the review of clinical records, it was determined that the facility failed to ensure that residents had the right to participate in the development and implementation of a person-centered plan of care for 2 out of 20 residents reviewed (Resident R61 and R71). Findings include: Review of October 2024 physician orders for Resident R61 indicated that the resident was admitted into to the facility on July 1, 2024 with diagnosis of muscle weakness and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), pancreatitis (a condition in which the pancreas becomes inflamed); anemia (an individual does not have enough healthy red blood cells which can result in fatigue and unexplained weakness); paraplegia (a form of paralysis that affects the lower half of an individual's body and their ability to walk), heart failure (an individual's heart can't supply enough blood to meet the body's needs),…
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 before2024-11-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of care and services, reviews of clinical records and interviews with residents and staff, it was determined that the facility failed to provide care preferences and reasonable accommodations for the adaptive equipment used to enhance mobility and bathing for one of three residents reviewed. (Resident R10) Findings include: Review of Resident R10 annual comprehensive assessment (MDS-an assessment of care needs) dated August 16, 2024 indicated that Resident R10 was cognitively intact with impairments on both sides of lower extremities. The assessment revealed that the resident required maximal assistance with functional abilities for showering and bathing, the use of a wheeelchair for ambulation. The resident was occasionally incontinent of bladder and occasionally experiencing pain. Continued review of the MDS revealed that the resident had a Stage II (ulcer involveing loss of the top layers of the skin) pressure sore, the resident received physical therapy and that the established goal set…
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 before2024-11-12 · 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 staff interview and the review of the clinical record, it was determined that the facility failed to ensure that a person-center plan of care was developed for a resident with a history of deep vein thrombosis (blood clots) and anticoagulant medications for 1 out of 20 residents reviewed (Resident R61). Findings include: Review of October 2024 physician orders for Resident R61 include the diagnose of muscle weakness, seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), pancreatitis (a condition in which the pancreas becomes inflamed); anemia (an individual does not have enough healthy red blood cells which can result in fatigue and unexplained weakness); paraplegia (a form of paralysis that affects the lower half of an individual's body and their ability to walk) and heart failure (an individual's heart can't supply enough blood to meet the body's needs). The resident also had a diagnoses of deep vein thrombosis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to develop and implement an effective discharge planning process for 1 out of 20 residents reviewed (Resident R61). Findings include: Review of the facility policy, Discharge Planning Policy, with a revision date of September 24, 2024, indicated that the discharge needs of each resident will be identified and will develop a discharge plan that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition the resident to post discharge care, and the reduction of factors leading to preventable readmissions. The policy also stated that the discharge plan will include: the regular re-evaluation of residents to identify changes that need to be made in the resident's discharge plan; the involvement of the interdisciplinary team (the physician, nurse, nurse aide, food and nutritional services staff), in addition to the resident and/or his/her responsible party. Review of October 2024 physician…
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.
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- Potential for harm · Dcited before2024-11-12 · 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 staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to notify the physician regarding a change in Resident R61's meal and fluid consumption for 1 out of 20 residents reviewed (Resident R61). Findings include: Review of the facility policy, Change in Condition, with a revision date of June 27, 2024, indicated that a resident's significant change in condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; impacts more than one are of the resident's health status and or requires interdisciplinary reviewed and /or revision to the care plan. The policy also indicated the physician and the resident/family and responsible party will be notified when there has been an accident involving the resident .a significant change in the resident's physician/emotional/mental condition and a need to alter the resident's treatment, including a change in provider orders .when there is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, interviews with staff and residents, it was determined that the facility failed to ensure the availability of necessary emergency tool kit for one resident, out of the six residents receiving hemodialysis (R36). Findings include: A review of the clinical record revealed that Resident R36 was admitted to the facility on [DATE], with a diagnosis of End Stage Renal Disease. Review of physician order for Resident R36, dated August 26, 2024, indicated an order to receive dialysis on Monday, Wednesday, and Friday. The physician order also indicated for an emergency tool kit (clamp, gauze, and tape) with the Resident R36, at all times during every shift, day shift, and night shift, at bedside. An observation and interview with Resident R36, on November 5, 2024, at 9:44 a.m., revealed there was no emergency tool kit located in the resident's room, or with the resident, or any Emergency Clamp at bedside. Absence of emergency tool kit was confirmed with Resident R36 and 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 · D2024-11-12 · 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
Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders, for one of seven residents' medication administration observed, resulting in a significant medication error (Resident R21). Findings include: On November 6, 2024, at 10:28 a.m., observed that Employee E12, a Registered Nurse, administered to Resident R21, the medicine, Furosemide tablet 40 mg, one tablet by mouth. Review of physician order for R21, revealed an order to administer Furosemide tablet 40 mg, two tablets, by mouth, for Obstructive and Reflux Uropathy (Obstructive Uropathy occurs when urine cannot drain through the urinary tract; urine backs up into the kidneys and may cause them to become swollen. Obstructive Uropathy is a prevalent cause of acute kidney injury that can potentially lead to death or irreversible and permanent tissue damage leading to chronic kidney disease). At the time of the observation, interview with Employee E12, confirmed the above findings. The facility incurred a medication…
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 · F2024-02-02 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: An initial tour of the Food Service Department was conducted on January 29, 2024, at 9:55 a.m. with Employee E9, Food Service Director, which revealed the following: Observations in the receiving area revealed piles of cardboard and leaves at the receiving enterance door which allowed pest harborage (conditions or place where pests can obtain water or food, nest, or obtain shelter). Further observation in the receiving area revealed significant amount of cigarette buds (50-100 count), at the door. Interview with the Food Service Director conducted on January 29, 2024, at approximately 10:26 a.m. confirmed the above mentioned findings. Further interview revealed that the food receiving area was also a smoking area for staff and acknowledged that the cigarette buds should have been cleaned up to maintain sanitary conditions in the food receiving area. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(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 · D2024-02-02 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of clinical records, facility investigation, and interviews with residents and staff, it was determined that the facility failed to treat residents with respect and dignity for three of 20 residents reviewed. (Resident R242, R37, R39) Findings Include: Review of facility investigation dated October 16, 2023, revealed that Resident R242 reported that his nurse aide said she wished the facility would stop taking heavy ass people to save her back while turning him for care on October 15, 2023. Review of statement from Employee E13, nurse aide, who provided care to Resident R242, confirmed that she stated to her co-worker that she wishes that the facility would stop taking heavy ass people to save her back while repositioning Resident R242 to provide care. Interview with the facility administrator and director of nursing on January 29, 2024, at approximately 2:00 p.m. confirmed the statement made by the Nurse aide, Employee E13. On February 1, 2024, at 9:23 a.m. an interview was held with Resident R37 who reported that during the third week of January 2024, 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 before2024-02-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident and staff interview, it was determined that the facility failed to answer call bells in a timely manner for four of 20 residents (Residents R34, R57, R82, R25), failed to accommodate the residents' needs related to having access wheelchair accessible bathroom including sink and toilet for one of the two residents reviewed (Resident R72) and the use of bed rails for 2 out of 20 residents observed.(Resident R25 and Resident R18) Findings include: Review of the facility Resident Communication System and Call Light Policy dated February 24, 2023, indicated It is the policy of the facility to provide residents with a means of communicating with staff. A call system is instilled in each resident room and toilet/bath areas. The facility responds to resident needs and requests. On January 29, 2024, at 10:30 a.m. an observation was taken place on the B unit nursing station that call bell monitor was ringing in room A8-D and was on for 23 minutes before it 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.
- Potential for harm · D2024-02-02 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to support and accommodate a resident's choices and preferences for one of two residents reviewed (Resident R72). Findings include: Review of Resident R72's quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated January 12, 2024, revealed that the resident was cognitively intact. Review of Resident R72's clinical record revealed an admission date on January 5, 2024 with the resident's diagnoses of muscle weakness, morbid (severe obesity due to excess calories), other acute osteomyelitis left ankle and foot, type 2 diabetes with mild nonproliferative diabetic retinopathy with macular edema bilateral, legal blindness as defined in USA, dependence on renal dialysis, hypertensive heart and chronic kidney diseases with heart failure and stage 1 through stage 4 chronic kidney disease, difficulty in walking, chronic embolism and thrombosis of unspecified vein, peripheral vascular diseases, anemia in chronic kidney 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.
- Potential for harm · D2024-02-02 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information and phone communication on two of six nursing units (A unit). Findings include: During a screaming observation on January 29, 2024, at 1:25 p.m. the medication cart used by Licensed Nurse, Employee E5 outside of room A15 on the A unit was left unattended with the computer screen open with identifiable information so any passerby could see resident personal and confidential information. On January 29, 2024, at 1:28 p.m. Employee E12, Assisting Director of Nursing was asked to do an observation in room A15 with Resident R295 and came across the medication cart, recognized the unattended cart and lowered the top screen of the computer. It was confirmed by ADON that licensed nurse, Employee E5 was not near on the A wing unit & hallway, but in some resident's room administering medication. Employee E12 ADON confirmed the observation of medication cart being unattended. 28 Pa. code: 211.5(b) Clinical records. 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 · D2024-02-02 · 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 review of facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to ensure that one resident remained free from abuse of 20 residents reviewed. (Resident R3) Findings include: Review of facility policy, Pennsylvania Resident Abuse revised August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Further review revealed that it is the facility policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Further review of facility policy revealed that facility staff must immediately report all such allegations to the administration . Review of Resident R3's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 22, 2023, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to discharge for one of four closed records reviewed (Resident R302). Findings include: Review of the discharge MDS assessment (Minimum Data Set, a periodic assessment of resident care needs) for the resident dated December 20, 2023, revealed that in section A, Identification Information, it was documented that the resident was discharged to an Planned. Interview with the MDS Coordinator, Employee E10, on February 1, 2024, at 12:16 p.m. confirmed that Resident R302's discharge should have been coded as Unplanned as the resident only been at the facility for two days and did not complete the rehabilitation. The discharge status had been coded in error. February 2, 2024, at 12:40 p.m. it was confirmed by the Administrator, Employee E1 that Resident R302's MDS was coded in error. 28 Pa. Code 211.5(f) Clinical records
- Potential for harm · D2024-02-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Pennsylvania's Nursing Practice Act, facility policies, interviews and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments and medication were performed in accordance with professional practices for one of one residents reviewed (Resident 295). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. On January 30, 2024, 1:10 p.m. an interview was held with Resident R295 who reported that I have pain during my care, there's not enough powder for my soreness in my butt anal area. Resident R295 reference a Nystatin medication powder that was on her tray and said it's almost out and I need this for nursing assistance when they do my…
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 before2024-02-02 · 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 closed record review, review of facility documents and interview with staff, it was determined that the facility failed to ensure that a physician's orders was followed related a psychotropic medication one of four closed records reviewed. (Resident R302) Findings include: Review of the closed record revealed that Resident 302 was admitted to the facility on [DATE], and discharged on December 20, 2023, with a bipolar disorder current episode manic severe with psychotic features (a mental health condition characterized by episodes of mania (or hypomania) and depression. When someone experiences a manic episode with psychotic features, it means they are in a state of elevated mood, energy, and sometimes psychosis). Review of hospital records indicated that Resident R302 was prescribed Quetiapine 25 milligrams (mg) tablet commonly known as Seroquel take 1.5 tablets, 37.5 mg total by mouth 3 times a day. Last time given December 18, 2023, to treat agitation. Review of the clinical record at the facility did…
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 · D2024-02-02 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, review of clinical record, observations, and interviews with staff and residents, it was determined that the facility failed to administer a resident's tube flushes per physician orders for one of one resident reviewed receiving enteral nutrition. (Resident R79). Findings include: Review of facility policy titled, Enteral Feeding Tube Policy dated, December 22, 2023, revealed that tube flushes must be performed according to physician direction or, n the absence of an order . Further review revealed that the enteral tube sites will be monitored daily and observed for drainage quantity, odor, and appearance. Review of Resident R79's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including malnutrition (occurs when the body doesn't get enough nutrients) and had a feeding tube (PEG- abdominal). Review of nutrition progress notes for Resident R79 revealed a note dated, December 20, 2023, which stated that the resident not receiving tube…
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 · D2024-02-02 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 reviews and interviews with staff, it was determined that the facility failed to provide mental health services to a resident with a mental disorder for one of 20 residents reviewed (Resident R302). Review of the closed record revealed that Resident 302 was admitted to the facility on [DATE], and discharged on December 20, 2023, with a bipolar disorder current episode manic severe with psychotic features (is a mental health condition characterized by episodes of mania (or hypomania) and depression. When someone experiences a manic episode with psychotic features, it means they are in a state of elevated mood, energy, and sometimes psychosis). Hospital record indicated Resident R302 had a prescription of Quetiapine 25 mg tablet commonly known as Seroquel take 1.5 tablets (37.5 mg total by nouth 3 times a day. Last time given December 18, 2023, to treat agitation. Review of the clinical record at the facility did not indicate that this medication was ordered by the facility physician, nor…
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 · D2024-02-02 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review and resident and staff interview, it was determined that the the faciltiy failed to provide a diet in accordance with resident's preference for one of 20 residents reviewed. (Resident R43) Finding include: Review of physician's order for Resident R43 revealed an order for LCS (limited concentrated sweets) Double Protein diet, Regular texture, thin consistency with an order date of February 4, 2023. Review of Resident R43's lunch meal ticket dated January 29, 2024, revealed that diet order was Regular double protein, low concentrated sweets, thin liquids. Further, meal ticket indicated a note stating: 2X Protein, no beets regular milk. Interview with Resident R43 conducted on January 29, 2024, 12:03 p.m. revealed that she doesn't get the right amount of food. Further Resident R43 revealed that she was supposed to get double protein but only gets one portion. Observation of Resident R43's meal tray conducted at the time of the interview revealed that there was one bun with a grayish brown patty in the bun with fries on the side. Further,…
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 · D2024-02-02 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents and review of clinical record and staff and resident interviews, it was determined that the facility failed to ensure a resident and resident's representative had the capacity to understand the terms of a binding arbitration agreement for 4 of 5 residents reviewed (Residents R72, R86, R29, R59). Findings include: On October 30, 2024, at 1:22 p.m. an interview was held with Resident R86 who reported when asked if arbitration agreement was explained. R86 responded not really explained I remember signing but I didn't understand it, no on explained to me about 30 days or what arbitration process was. Review of the resident's Minimum Data Set (assessment of resident care needs), indicated that a Brief Interview for Mental Status (BIMS) dated December 7, 2023, revealed Resident R86 had a BIMS score indicated 15 - cognitively intact. Review of Resident R86's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have…
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 · D2024-02-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review facility policy and review of facility documents and interview with staff, it was determined that the facility did not maintain an effective infection prevention program related to hand hygiene during wound care observation and medication administration for five of eight residents observed. (Residents R295, R4, R84, R48, R65 and R8) Findings: Review of facility policy on hand hygiene with most recent revision date of May 3, 2023, under section Policy: Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. Under section procedure. #1. Proper hand washing technique is to be accomplished when visibly dirty or contaminated with proteinaceous material, or visibly soiled with blood or other body fluids, or if exposure to potential spore forming organisms is strongly suspected or proven. And after using the restroom. #2. Referable to use an alcohol-based rub for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of facility records, observations and interviews with resident and staff, it was determined that the facility failed to ensure a sanitary environment on one three of three nursing units observed. (C unit) Finding Include: On January 29, 2024, at approximately 10:07 a.m. a significant urinal odor was detected on the C unit near room C43. On February 1, 2024, at 9:23 a.m. an observation was taken place with Housekeeping Director, Employee E15 who reported room B27 has a significant unsanitary odor. The root cause Employee E15 reported that Resident R39 and Resident R37 refuse care. Both residents agreed to take showers as it was their shower days and investigate where the significant odor was coming and prevent future reoccurrences. On February 1, 2024, at 10:03 a.m. an observation with the housekeeping Director, Employee E15 confirmed a strong urine smell in room C43 and stated, we'll get someone in here immediately. There were four male residents resigning in the room. On February 1, 2024, at 11:20 a.m. the Director of Nursing, Employee E2 revealed that Resident…
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 · D2023-10-27 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor meal and nutritional supplement consumption for one of six residents reviewed. (Resident CL1) Findings include: Review of facility policy, Weights Policy revised February 1, 2020, revealed that a significant weight change is defined as 5% weight loss of more in one month; 7.5% or more in three months; and 10% or more in six months. Review of Resident CL1's admission Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated August 16, 2023 revealed that the resident was admitted to the facility on [DATE], and had the diagnoses including diabetes a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), renal disease (a condition characterized by a gradual loss of kidney function over time), and liver failure (when the liver has…
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 · B2024-10-02 · tag F0622 — patternNot 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 review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required. Findings include: Documentation of notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past six months was requestedon October 1, 2024, at 10:48 a.m. from Employee E2, Director of Nursing (DON). A follow-up telephone call with the Administrator on October 2, 2024, at 11:03 a.m. confirmed that they had received the request, that they were working on this request, and they would send the information electronically by email. A telephone interview with the DON on October 2, 2024, at 1:32 p.m. confirmed that the facility did not have documentation to prove that the facility sent the notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past six months. She indicated that the facility had been sending…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 125 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 125; 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 |
|---|---|---|---|---|
| SHG RECS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/02/2022 |
| SABER PA HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/31/2023 |
| WWBV HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/30/2019 |
| BHATIA, SANJAY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 11/30/2010 |
| WOODWARD, CINDY | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2018 |
| VOLPE, BENJAMIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| WEISBERG, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| NICOLUZAKIS, GREGORY | Individual | CORPORATE OFFICER | — | since 03/01/2019 |
| SABER GOVERNANCE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2019 |
| MEENAN, CODY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395259. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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.