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William Penn Nursing And Rehab

163 Summit Drive, Lewistown, PA 17044 · For profit - Limited Liability company · 121 certified beds · (717) 248-3941 Medicare & Medicaid certified

Call the home — (717) 248-3941 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
27 Sandy Ln · (717) 242-8907 · Call to confirm hours
Pharmacy
Cvs0.4 mi
404 N Logan Blvd · (717) 248-3991 · Call to confirm hours
Grocery
325 W Freedom Ave · (717) 248-3963 · Call to confirm hours
Park
Kish Park0.5 mi
1 Derry Park Dr · (717) 248-6870 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 4 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 held steady at 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.2%16.8%15.4%worse
Long-stay residents who lose too much weight0.9%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.7%0.9%better
Long-stay residents with a urinary tract infection0.8%1.5%2.0%better
Long-stay residents with depressive symptoms1.6%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury1.8%3.1%3.3%better
Long-stay residents whose ability to walk worsened23.8%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication32.1%20.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers2.1%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control20.9%25.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table24.1%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.8%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine97.3%68.7%79.4%better
Short-stay residents rehospitalized after admission15.5%22.5%22.6%better
Short-stay residents with an outpatient ER visit6.4%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.321.621.67better
Long-stay outpatient ER visits per 1,000 resident days0.361.181.80better

§ 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.

59.1% 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 118 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.1%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
48.6%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 48.6% 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 74 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 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.1%CMS range 48.7–65.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.2–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.4–12.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.731.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.54
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.31
RN hoursweekends
35.6%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 121 beds and averages 116.8 residents a day — about 97% occupied, or roughly 4 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.13 hrs/resident/day on weekends vs 3.50 on weekdays — 11% thinner on weekends. RN hours go from 0.63 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 36% 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

8
deficiencies at the latest standard inspection (2026-04-17)
7
at the previous standard inspection (2025-05-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · Ecited before2026-04-17 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 63 and 79).Findings include:The facility's medication error rate was 12 percent based on 25 medication opportunities with three medication errors.Observation on April 17, 2026, of Resident 79's medication administration at 8:28 AM revealed that Employee 3, licensed practical nurse, administered one 20 mg (milligram) tablet of Lasix (a diuretic medication used to treat fluid retention). Clinical record review for Resident 79 revealed a physician order dated April 6, 2026, stating, Furosemide 20 MG Tablet TAKE THREE TABLETS (60MG) BY MOUTH ONCE DAILY RELATED TO EDEMA, UNSPECIFIED. Concurrent observation of Resident 79's medication administration revealed that Employee 3 administered two tablets of Potassium Chloride Crys ER (Extended Release) Oral 20 MEQ (milliequivalent), and broke both tablets in half prior to administration. The medication reference Drugs.com (a comprehensive and widely…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 1, dietitian, on April 14, 2026, at 10:12 AM revealed the following: The wall mounted soap dispenser located adjacent to the handwashing sink was coming off the wall. The walk-in freezer contained a box of bagged broccoli cuts and lima beans that were open to the ambient air. The spice rack contained the following outdated containers of spices: ground all spice with a use by date of July 19, 2024; rosemary with a written use by date of September 19, 2024; thyme with a use by date of March 6, 2025. The dry goods storage area contained a container of whole bay leaves with a written use by date of December 20, 2024. There was a bent adaptive piece of silverware in a drawer on the table that held the coffee machine. The piece of silverware had a discolored piece of scotch tape on the handle. Employee…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate transmission-based precautions (TBP) for two of three residents reviewed on TBP (Residents 127 and 129).Findings include: The facility policy entitled Transmission-Based (Isolation) Precautions, last reviewed without changes on March 19, 2026, revealed it is the facility policy to take appropriate precautions to prevent transmission of pathogens, based on pathogens' modes of transmission. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident, or the resident's environment. Facility staff will apply transmission-based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The category of transmission-based precautions will determine the type of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-17 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 23 residents reviewed (99).Findings include: Clinical record review for Resident 99 revealed a MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 21, 2026, that facility staff assessed Resident 99 as receiving an anticoagulant medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 99 received an anticoagulant medication during the assessment period for the MDS noted above.Interview with the Director of Nursing on April 16, 2026, at 2:07 PM confirmed that Resident 99's February 21, 2026, MDS was coded in error regarding receiving an anticoagulant medication. 483.20(g) Accuracy of AssessmentsPreviously cited 5/9/25 28 Pa. Code 211.5(f)(ix) Medical records28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan for infection control concerns for two of 23 residents reviewed (Residents 127 and 128).Findings include: Clinical record review revealed the facility admitted Resident 127 on April 5, 2026. A physician order dated April 5, 2026, revealed staff were to initiate contact precautions (measures to prevent the spread of infections transmitted by direct/indirect contact with a resident or their environment) for Resident 127 for VRE (vancomycin resistant enterococci, a type of bacteria resistant to the antibiotic vancomycin) in her foot wound. Further review of Resident 127's clinical record revealed her care plan-initiated April 5, 2026, listed infection of and was blank after. The care plan noted staff were to maintain isolation precautions as indicated but did not specify what. Clinical record revealed the facility admitted Resident 128 on April 5, 2026. A physician order dated April 6, 2026, revealed staff were to initiate contact…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, observation, and staff, it was determined that the facility failed to ensure the highest practical care related to PICC lines (peripherally inserted central catheter, provides access to the large veins near the heart by inserting a thin flexible tube into a vein the upper arm) for two of 23 residents reviewed (Residents 127 and 128). Findings include: Clinical record review revealed the facility admitted Resident 128 on April 5, 2026. Nursing documentation dated April 6, 2026, at 4:48 PM, revealed Resident 128 stated, he wanted a pair knife to cut his line. Documentation revealed Resident 128 then tried to pull at his PICC line. Further review of Resident 128's clinical record revealed a physician order dated April 5, 2026, for staff to maintain an emergency kit for Resident 128's PICC line at his bedside. Observation of Resident 128's room on April 14, 2026, at 1:05 PM revealed there was no emergency kit visible in his room. Further observation on April 15, 2026, at 10:02 AM, revealed a small bag of gauze in his top dresser drawer under his personal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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

    Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies and provide care consistent with professional standards of practice for one of one resident reviewed receiving hemodialysis (Resident 10).Findings include: Clinical record review for Resident 10 revealed a diagnosis list that included the following related to hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities): end stage renal disease, chronic kidney disease, and an arteriovenous (AV) fistula (surgically created connection between an artery and a vein to provide an access for hemodialysis). Review of the current physician orders for Resident 10 revealed the following: An order dated August 24, 2025, noted, dialysis precautions: no blood draws, injections, or blood pressure from (specify) arm. Emergency kit at bedside containing appropriate equipment; tourniquet, sterile gauze, gloves, etc. Nursing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for one of five residents reviewed for immunizations (Resident 3).Findings include: The facility policy entitled Pneumococcal Vaccine, last reviewed without changes revealed March 19, 2026, revealed it is the facility policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Each resident will be assessed for pneumococcal immunizations upon admission. Each resident will be offered a pneumococcal immunization unless it is contraindicated, or the resident has already been immunized, the type of pneumococcal vaccine (PCV15, PCV20, PCV21, or PPSV23) offered will depend upon the recipient's age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with current CDC guidelines and recommendations. Clinical record review revealed the facility admitted Resident 3 on December…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-09 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for six of 26 residents reviewed (Residents 4, 14, 20, 71, 75, and 81). Findings include: Clinical record review for Resident 75 revealed a Quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 2, 2025. The facility staff assessed the resident as taking an anticoagulant (a medication that prevents or reduces clotting time of the blood). Further clinical record review revealed no evidence that Resident 75 was on an anticoagulant. An interview with Employee 2, registered nurse assessment coordinator (RNAC), on May 7, 2025, at 10:50 AM confirmed that Resident 75 was not on an anticoagulant during the assessment period, and this was marked in error on the MDS. The Nursing Home Administrator and Director of Nursing were informed of the above findings during a meeting on May 7, 2025, at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-09 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for 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 clinical record review, observation, and staff and resident interview, it was determined that the facility failed to assist residents to obtain routine dental care for six of eight residents reviewed (Residents 34, 50, 95, 4, 20, and 37). Findings include: Observation of Resident 34 on May 7, 2025, at 10:23 AM revealed that she had some natural teeth. Resident 34 was unable to be interviewed due to her current cognitive status. Clinical record review revealed the facility admitted Resident 34 on January 8, 2018, with payment sources that included the state Medicaid benefit. Further review of Resident 34's clinical record revealed that she last saw a dentist on February 13, 2020. An interview with Employee 1 (licensed practical nurse) on May 8, 2025, at 11:34 AM confirmed these findings for Resident 34. There was no other documentation that indicated Resident 34 was offered routine dental services every six months as the State plan allows. Observation and interview with Resident 50 on May 6, 2025, at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · E2025-05-09 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, it was determined that the facility failed to maintain COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network for one of one staff reviewed (Employee 3). Findings include: The surveyor requested information regarding the COVID-19 vaccination status for the facility's current employees during an interview with Employee 4 (Registered Nurse, Infection Preventionist), on May 9, 2025, at 11:00 AM. Employee 4 indicated that she has not been tracking vaccination status for staff. She also indicated that she had no evidence of offering COVID-19 vaccinations to staff because they do not ask each staff member individually as they post a sign by the time clock and in the employee breakroom indicating that if staff were interested in receiving a vaccine that they need to visit their primary care physician or local pharmacy. The Nursing Home Administrator and Director of Nursing were made aware of concerns related to staff COVID-19 vaccinations on May 9, 2025, at 11:35…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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

    Based on review of select facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide dignity regarding covering urinary catheter bags for one of one resident reviewed for catheters (Resident 87). Findings include: Clinical record review for Resident 87 revealed a current physician's order for them to have a Foley urinary catheter to straight bag drainage for urinary retention. Observation of Resident 87 on May 6, 2025, at 12:58 PM, May 7, 2025, at 11:02 AM, May 8, 2025, at 12:42 PM and May 9, 2025, at 10:15 AM revealed that they were in bed with the urinary catheter bag hanging on the side of the bed uncovered. During the May 6, 2025, at 12:58 PM observation, the catheter bag was on the door side, in full view from the hallway, and visible to all passing. During the May 7, 2025, at 11:02 AM observation, the bag was on the window side of the bed, lying on the floor, in full view from the hallway, and visible to all passing. During the May 8, 2025, and May 9, 2025, observation, the catheter bag was on the window side 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Clinical record review and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs related to call bell response time for two of 26 residents reviewed (Residents 50 and 66). Findings include: In an interview with Resident 50 on May 6, 2025, at 12:56 PM she stated that she has waited an hour to go the bathroom. She stated that she is usually only incontinent when she rings her call bell and must wait a long time for staff to assist her. Resident 50 stated that the licensed practical nurse will come into her room and turn off her call bell stating they will let the nurse aide know but nobody comes back. Clinical record review for Resident 50 revealed her most recent annual MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) assessment dated [DATE], indicated Resident 50 was cognitively intact and occasionally incontinent of her bladder function. Resident 50 filed a grievance on January 1, 2025,…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (Station Two Nursing Unit; Honey Creek Hall). Findings include: Observation during the medication pass on the Station Two Nursing Unit (Honey Creek Hall) on May 9, 2025, at 9:35 AM revealed a medication cart being utilized by Employee 5, licensed practical nurse. Observation of the medication cart revealed the following: There was a significant accumulation of debris and dirt including hair in the bottom of the drawers. There were several unsecured and unidentified medication tablets found in the drawer that contained the medication punch cards that included several unidentified pills: two white colored round pills, two orange colored round pills, a multi-colored capsule, and a large brown colored pill. The above findings were reviewed in a meeting with the Director of Nursing on May 9, 2025, at 9:57 AM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-25 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for 10 of 24 residents reviewed (Residents 9, 19, 32, 41, 55, 60, 63, 85, 97, and 109). Findings include: Interview with Resident 60 on June 23, 2024, at 10:38 AM revealed that she denied ever having a physical restraint. Resident 60 indicated that she is unable to transfer herself out of bed, and that a staff member utilizes a stand-up mechanical lift to transfer her out of bed to a chair. Clinical record review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment for Resident 60 dated May 4, 2024, revealed that staff assessed the daily use of a bed rail as a restraint. The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument, MDS) Manual for Item P (Physical Restraint) instructs that if the resident is immobile and cannot voluntarily…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to provide a clean, comfortable environment in two shower rooms located on one of two nursing units (Nursing Unit 1, Windmill Hill). Findings include: Interview with Employee 3, nurse aide, on June 23, 2024, at 11:55 AM revealed that the staff utilize both shower rooms on Nursing Unit 1. The larger of the shower rooms is mainly utilized; however, the smaller shower room across the hall is used if the other shower is occupied. Observation of the larger shower room on June 23, 2024, at 11:56 AM revealed the following: A dislodged piece of tile on the floor that appeared to be from around the drain area in the floor. Two ceiling lights had debris that included dead insects in the protective coverings. The tiled floor in the shower had a build-up of grime and stains. The paint on the ceiling above the shower area was peeling in multiple areas. A ceiling light above the commode had debris and a dead insect in the protective covering. A metal hand hygiene product dispenser base was attached to the wall near the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-25 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a significant change MDS assessment was completed timely after election of hospice care for one of two residents reviewed (Resident 103). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (RAI, reference used to complete an MDS) revealed that the facility must complete a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine care needs) no later than 14 days after the effective dated of the election of hospice. Clinical record review for Resident 103 revealed that on June 6, 2024, their physician ordered hospice care. There was no documentation indicating that the facility completed a significant change MDS as indicated by the RAI Manual until after identified by the surveyor. The surveyor reviewed the above findings during an interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at 2:00 PM. 28 Pa. Code 211.5 (f) Clinical records

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and resident and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for two of 26 residents reviewed (Residents 41 and 81). Findings Include: Interview with Resident 41 on June 22, 2024, at 2:00 PM revealed that she is legally blind from macular degeneration (an eye disease that causes a gradual breakdown of the cells in the part of the eye that is responsible for central vision). Clinical record review for Resident 41's plan of care revealed that there was no care plan related to her vision loss. This information was reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) during an interview on June 23, 2024, at 2:07 PM. A care plan for Resident 41 related to her impaired vision was provided to the surveyor on June 24, 2024, at 8:55 AM. The care plan indicated that it was initiated on September 14, 2020. Review of the care plan history in the facility's computerized documentation system, revealed that the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care related to intravenous access for one of one resident reviewed for intravenous access concerns (Resident 80). Findings include: The facility policy entitled, Midline Dressing Changes, last reviewed without changes on March 21, 2024, revealed that general guidelines include to change the midline catheter dressing every five to seven days or if wet, dirty, not intact, or compromised in any way. Label the dressing with initials, date, and time. The policy did not include interventions implemented into a resident's plan of care to prevent infection or other complications from the use of a midline. The policy did not include routine assessments needed to monitor the resident during the presence of a midline catheter. Clinical record review for Resident 80 revealed nursing documentation dated June 3, 2024, at 2:33 PM that Resident 80 presented on admission with a, PICC…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-25 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement interventions to treat hearing loss for one of two residents reviewed for hearing concerns (Resident 31). Findings include: Interview with Resident 31 on June 22, 2024, at 11:56 AM revealed that she had difficulty hearing and required the use of a dry erase board to communicate. Clinical record review of documentation from the facility's contracted audiology professional dated August 18, 2023, indicated that the assessment/plan for Resident 80 confirmed that she had sensorineural hearing loss (hearing loss resulting from damaged hair cells in the inner ear) bilaterally. The documentation indicated that staff reported that they write notes when needed. The provider's recommendation was a trial of a pocket talker (personal sound amplifier) to aid in hearing for communication of needs. A plan of care developed by the facility to address Resident 31's hearing loss included no reference to the use of a pocket talker. Interview with the Director of Nursing and the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's range of motion for one of two residents reviewed (Resident 55). Findings include: Clinical record review for Resident 55 revealed a current physician's order for staff to provide a restorative program (range of motion, ROM, movement of the body in an attempt to maintain a resident's ability) to prevent contracture(s), which included left lower extremity (LLE) ROM passive stretching to left leg into knee extension times five repetitions and holding for 30 seconds, to be completed with AM (morning) and PM (evening) care. Review of task documentation for Resident 55 for April, May, and June 2024, revealed that staff did not document completion of the restorative task on the following dates: Day Shift: April 13 and 14, 2024 May 21, 28, and 29, 2024 (documented not applicable) May 24, 25, and 26, 2024 (no documentation) June 8 and 9, 2024 Evening Shift: April 1, 3, 4, 5, 7, 9, 10, 13, 24, 16, 18, 19, 23, 24, 27, and 28, 2024 May…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to implement supplemental oxygen per physician orders for one of one resident reviewed for oxygen concerns (Resident 80). Findings include: The facility policy entitled, Departmental (Respiratory Therapy) - Prevention of Infection, last reviewed March 21, 2024, revealed that the purpose of the procedure was to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Preparation included a review of the resident's care plan to assess for any special circumstances or precautions related to the resident. Infection control considerations related to medication nebulizers/continuous aerosol equipment included to store the circuit in a plastic bag, marked with the date and resident's name, between uses. Interview with Resident 80 on June 22, 2024, at 12:45 PM, revealed that she was diagnosed with rhinovirus (virus that is the most frequent cause of the common…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 57). Findings include: Review of Resident 57's clinical record revealed a note from the pharmacist to the attending physician dated September 7, 2023, that requested a gradual dose reduction of her Escitalopram (Lexapro, a medication used to treat depression) 10 milligrams (mg) daily. The physician responded on September 13, 2023, by checking the box that read other and wrote, current dose beneficial, with no further explanation. Clinical record review of Resident 57's behavior documentation on the Medication Administration Record (MAR) for September 2023, related to the medication Escitalopram, revealed no behaviors documented related to her diagnosis of depression. Further review of Resident 57's clinical record revealed a pharmacist note to the attending physician dated February 12, 2024, that requested a trail dose reduction of her Ativan (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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, observation, and staff interview, it was determined that the facility failed to have a medication error rate less than five percent (Residents 77 and 80). Findings include: The facility's medication error rate was 6.67 percent based on 30 medication opportunities with two medication errors. Observation of a medication administration pass on June 23, 2024, at 8:46 AM revealed Employee 1 (registered nurse) administered Omeprazole (medication used to reduce stomach acid) 20 milligrams (mg) to Resident 77. Resident 77 had finished her breakfast meal. Interview with Employee 1 on June 23, 2024, at 12:57 PM confirmed that Resident 77 received her Omeprazole medication after she had consumed her breakfast. Review of https://www.drugs.com revealed that it is usually best to take Omeprazole one hour before meals. When omeprazole is taken with food it reduces the amount of omeprazole that reaches the bloodstream. Clinical record review for Resident 80 revealed a physician's order for staff to administer Fluticasone Propionate (Flonase, a steroid nasal spray…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of select facility policies and procedures, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to implement enhanced barrier precautions for one of three residents reviewed for infection control concerns (Resident 80). Findings include: The facility policy entitled, Enhanced Barrier Precautions, last reviewed without changes on March 21, 2024, revealed that enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include wound care (any skin opening requiring a dressing) and/or device care or use (central line, urinary catheter, feeding tube, etc.). Staff are trained prior to caring for residents on EBPs. Interview with Resident 80 on June 22, 2024, at 12:46 PM revealed that she had an open sore on her right foot 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-05-09 · tag F0732 — widespread
    Post 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 post the daily nurse staffing information at the beginning of each shift for two of two nursing units reviewed (Nursing Unit One and Nursing Unit Two). Findings include: Observation of the nurse staffing information posted on the wall adjacent to the main lobby of the facility on May 8, 2025, at 11:19 AM and 12:38 PM revealed a nurse staffing sheet dated May 7, 2025. Observation at the Nursing Unit Two nurse station and concurrent interview with Employee 5, licensed practical nurse, on May 8, 2025, at 11:30 AM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse's station. Observation of Nursing Unit One nurse station and concurrent interview with Employee 6, social worker, on May 8, 2025, at 12:43 PM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse station. An interview with Employee 8, scheduler, on May 8, 2025, at 12:53 PM revealed that the posted nurse staffing information located near 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to VALLEY WEST HEALTH — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.3+0.7 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 53.1+1.9 vs chain
The other 11 homes this chain runs (chain average 3.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
WESTERN PA OPCO HOLDINGS I LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 10/29/2024
VALLEY WEST HEALTH LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/15/2024
FRANCO, AHARONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/29/2024
RAMI, ISAACIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/29/2024
KARITY, SARAHIndividualTRUSTEE OF THE SNF; ADP OF THE SNFsince 10/29/2024
BEVERLY ENTERPRISES - PENNSYLVANIA, INC.OrganizationADP OF THE SNFsince 12/20/2024
BEVERLY ENTERPRISES LLCOrganizationADP OF THE SNFsince 12/20/2024
BEVERLY HEALTH AND REHABILITIATION SERVICES, INCOrganizationADP OF THE SNFsince 12/20/2024
DRUMM INTERMEDIARY SUB CO LLCOrganizationADP OF THE SNFsince 12/20/2024
DRUMM MERGER COOrganizationADP OF THE SNFsince 12/20/2024
DRUMM MERGER CO SUB LLCOrganizationADP OF THE SNFsince 12/20/2024
FILLMORE STRATEGIC INVESTORS LLCOrganizationADP OF THE SNFsince 12/20/2024
GEARY PROPERTY HOLDINGS LLCOrganizationADP OF THE SNFsince 12/20/2024
GPH LEWISTOWN LPOrganizationADP OF THE SNFsince 12/20/2024
PEARL SENIOR CARE, LLC.OrganizationADP OF THE SNFsince 12/20/2024
SURETY COMPLIANCEOrganizationADP OF THE SNFsince 10/29/2024
WASHINGTON STATE INVESTMENT BOARDOrganizationADP OF THE SNFsince 12/20/2024
ANDREWS, HEATHERIndividualADP OF THE SNFsince 10/29/2024
FINN, NICHOLASIndividualADP OF THE SNFsince 10/29/2024
LINAM, KIMIndividualADP OF THE SNFsince 10/29/2024
MILLER, JEANIndividualADP OF THE SNFsince 11/15/2024
RASMUSSEN-JONES, HOLLYIndividualADP OF THE SNFsince 10/29/2024
ROSCOE, BRANDONIndividualADP OF THE SNFsince 12/20/2024
TRAXLER, TANAIndividualADP OF THE SNFsince 12/20/2024
WILLOW, TERESAIndividualADP OF THE SNFsince 12/20/2024

CMS files one row per role, so the 30 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

14 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.

$12.1M
Net patient revenuemost recent cost report
-15.1%
Operating marginrevenue minus expenses
$2.2M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 5%Other / private 22%

About 73% 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 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$330per resident / day
operating cost
$10,034per month
≈ monthly operating cost
$287per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395335. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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