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Lecom At Snyder Memorial

156 Snyder Memorial Rd, Marienville, PA 16239 · Non profit - Corporation · 100 certified beds · (814) 927-6670 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$25,853 in federal fines
Insights

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

Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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
  • the CMS record shows $25,853 in federal fines (most recent 2024-03-06)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 20% 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
32719 Route 66 # 2 · (814) 744-8525 · Call to confirm hours
Pharmacy
105 Faulkner Dr · (814) 755-3557 · Call to confirm hours
Grocery
32836 Route 66 · (814) 744-8811 · Call to confirm hours
Park
Maca0.7 mi
Pine St · (814) 927-6607 · Typically dawn to dusk
Place of worship
101 Hemlock St · (814) 226-7288

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 rating2★
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 increased20.6%16.8%15.4%worse
Long-stay residents who lose too much weight5.3%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.5%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 restrained0.5%0.2%0.1%worse
Long-stay residents with falls causing major injury4.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened27.4%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication38.3%20.0%18.9%worse
Long-stay residents given the seasonal flu vaccine81.7%93.5%95.3%worse
Long-stay residents with pressure ulcers5.8%4.8%4.7%worse
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 table59.1%17.7%17.1%check this — see note marked dagger below the table
Short-stay residents who newly got an antipsychotic medication6.5%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine31.6%68.7%79.4%worse
Long-stay hospitalizations per 1,000 resident days0.671.621.67better
Long-stay outpatient ER visits per 1,000 resident days1.441.181.80better

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.

36.4% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.4%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
0.19U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% 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 SNF36.4%CMS range 26.1–54.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.0–16.310.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified75.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%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 hospitalization6.4%CMS range 3.1–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 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

0.48
RN hours/ resident / day
1.09
LPN hours/ resident / day
2.18
Aide hours/ resident / day
3.76
Total nurse hours/ resident / day
0.30
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 100 beds and averages 96.8 residents a day — about 97% occupied, or roughly 3 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.26 hrs/resident/day on weekends vs 3.96 on weekdays — 18% thinner on weekends. RN hours go from 0.55 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-05-29)
5
at the previous standard inspection (2025-05-08)

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 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · K2024-03-06 · tag F0678 — failed to provide CPR when needed — pattern
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 established guidelines from the American Heart Association (AHA) for cardiopulmonary resuscitation (CPR - emergency life-saving procedure that is done when the heart stops beating and when performed immediately can double or triple chances of survival after cardiac arrest), facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide CPR as required for one of one resident reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident R1 became unresponsive and pulseless, facility did not administer CPR to Resident R1 as required. This failure placed 43 of 95 residents ( R2, R3, R4 R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21 R22, R23 R24 R25, R26, R27 R28, R29, R30, R31, R32 R33, R34, R35 R36, R37, R38 R39, R40, R41, R42, R43, and R44), that had requested to have CPR administered if they became unresponsive and pulseless, at a high risk for death and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-29 · tag F0711 — pattern
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for 22 of 26 Residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R12, R13, R14, R18, R20, R23, R26, R36, R49, R59, R76, and R85). Findings include: Facility policy entitled Physician Visits dated 5/13/26, revealed The attending physician must make visits in accordance with applicable state and federal regulation. The attending physician must visit his/her patient at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. and A physician visit is considered timely if it occur not later than ten (10) days after the date the visit 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-05-29 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 26 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Care Plans - Baseline dated 5/13/26, revealed The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following:The stated goals and objectives of the resident. A summary of the resident's medications and dietary instructions.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Review of Resident R1's clinical record revealed an admission date of 10/7/25, with diagnoses that included Asthma (a long-term lung disease that causes the airways to narrow and make it difficult to breath), hypothyroidism (a condition when the thyroid produces low amounts of thyroid…

    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 no plan of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 26 residents reviewed (Residents R6 and R85).Findings include: Facility policy entitled Care Plans, Comprehensive Person-Centered dated 5/13/26, revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident R6's clinical record revealed an admission date of 12/21/12, with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (a condition where urine cannot properly drain from the kidney due to blockage), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Resident R6's progress notes revealed a note dated 2/12/26, indicated that his/her urinary catheter was removed. Resident R6's Care Plan for altered genitourinary system dated 12/16/25, revealed interventions to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-05-29 · 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 — 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 and manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to appropriately discard outdated medications for one of two medications rooms (West) and one of four medication carts (West One). Findings include: Facility policy entitled Medication Labeling and Storage dated 5/13/26, revealed Multi-dose [NAME] that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30-days after opening. Review of manufacturer's guidelines revealed that and open vial of Insulin Glargine (also known as Lantus - medication used to treat diabetes) should be discarded within 28-days after opening. Observation of drug storage on 5/26/26, at 1:52 p.m. on the [NAME]…

    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 no plan of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 — the official record, unedited, may be distressing

    Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure food was prepared in a safe and sanitary manner in the dishwashing area of the main kitchen.Findings include: A facility policy entitled, Sanitization dated 5/13/26, revealed The food service area is maintained in a clean and sanitary manner .All utensils, counters, shelves, and equipment are kept clean. Observations conducted on 5/26/26, at approximately 10:40 a.m. of the main kitchen revealed one fan over the meal prep area and one fan in the dishwashing area with a thick layer of dust and a fuzzy substance. Interview conducted with the Kitchen Manager at that time confirmed that the one fan over the meal prep area and the one fan in the dishwashing area had a thick layer of dust and a fuzzy substance. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-05-29 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to dispose of trash in the garbage dumpster and failed to dispose of boxes in the recycling dumpster properly for two dumpsters observed outside of the building.Findings include:Facility policy entitled Sanitization dated 5/13/26, indicated Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpster/compactors with lids.Observations on 5/26/26, at approximately 12:30 p.m. of the garbage dumpster revealed several bags of trash heaping out of the container and the lid could not be closed and the recycling dumpster revealed several boxes heaping out of the container and the lid could not be closed.During an interview on 5/26/26, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the garbage dumpster had several bags of trash heaping out of the container and the recycling container had several boxes heaping out of the container, and that both containers lids could not be closed. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · E2025-05-08 · 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 review of the Resident Assessment Instrument (RAI-manual that guides facilities with completing resident Minimum Data Set [MDS-periodic assessment of resident care needs] assessments), clinical records, facility documentation, and staff interviews, it was determined that the facility failed to complete the MDS to accurately reflect the resident's status at the time of the assessment for seven of 21 residents reviewed (R8, R9, R13, R15, R41, R55, and R76). Findings include: Review of the October 2024 RAI Manual revealed that restraints (a device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) used in the seven-day assessment look-back period were to be documented in Section P (Restraints and Alarms) of the MDS, coding 0 for not used, 1 for used less than daily, and 2 for used daily. Review of Resident R8's clinical record revealed an admission date of 10/09/08, with diagnoses…

    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 · E2025-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of 25 residents reviewed (Resident R34). Findings include: Review of facility policy entitled Oxygen Administration dated 4/1/25, indicated Check physician's order for liter flow . Review of facility policy entitled Documentation, Clinical dated 4/1/25, indicated Documentation shall be done by nursing staff according to the needs of the resident and the care provided. Review of Resident R34's clinical record revealed an admission date of 7/6/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic respiratory failure (a condition where your lungs don't exchange air properly), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review of Resident R34's physician's orders revealed an order for O2 (oxygen) via NC (nasal cannula-oxygen tubing that has prongs that go into…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-08 · 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 facility policies and clinical records, observations, staff interviews, and resident interview, it was determined that the facility failed to maintain proper infection prevention and control isolation by failing to remove isolation precautions for non-transmittable diseases which were confirmed by laboratory testing for three of five residents reviewed on droplet precautions (a type of transmission based precautions used to prevent the spread of respiratory infections) (Residents R56, R77, and R33). Findings include: Review of the facility policy entitled Policy on Isolation and Infection Precautions dated 4/1/25, revealed when it is determined that a resident needs isolation or special infection precautions to prevent the spread of infection, the appropriate isolation and/or precautions are utilized. Review of the facility policy entitled Infection Prevention & Control Program dated 4/1/25, revealed prevention of spread of infections is accomplished by the use of Standard and Transmission based precautions and other barriers, appropriate treatment and follow-up…

    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 before2025-05-08 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 21 residents reviewed (Resident R34). Findings include: Review of facility policy entitled Care Plans dated 4/1/25, indicated The care plan will be reviewed, evaluated and updated with any significant change ., and Care plans will outline resident's care needs based on . physician orders . Review of Resident R34's clinical record revealed an admission date of 7/6/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic respiratory failure (a condition where your lungs don't exchange air properly), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review of Resident R34's physician orders revealed an order for O2 (oxygen) via NC (nasal cannula-oxygen delivery) 2-3LPM (liters per minute) continuous, goal sats (oxygen saturation percent) 88-92%,…

    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
Show the remaining 15 citations
  • Potential for harm · D2025-05-08 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility records and staff interview, it was determined that the facility failed to ensure required attendance of the Director of Nursing and Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings for two of four quarterly QAPI Committee meetings. Findings include: Review of facility policy entitled Leadership and Communication dated 4/1/25, indicated the facility will have a QAPI steering committee which included the following members Administrator, Director of Nursing, Infection Control, Medical Director . and Committee Members - Per CMS regulations . Review of the QAPI Committee Attendance Records for the October 2024 meeting revealed no evidence on the attendance sign-in for the required QAPI meeting that the Director of Nursing was in attendance. Review of the QAPI Committee Attendance Records for the February 2025 meeting revealed no evidence on the attendance sign-in sheets for the required QAPI meeting that the Infection Preventionist was in attendance. During an interview on 5/8/25, at 12:15 p.m. the 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-02 · 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 — 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 properly safeguard and administer resident medications for one of six residents reviewed (Resident R1). Findings include: Review of facility policy dated 10/11/23, entitled Medication Administration indicated that All medications shall be given by the person who prepared the dose. Assure that the resident has enough fluids to swallow their medication. Never leave medication at the bedside. Be sure that all medication is administered and that no medication remnants remain in the cup. Observation of Resident R1's room on 10/01/24, at approximately 11:25 a.m. revealed a medication cup from the morning medication pass with two pills identified as Eliquis 2.5 mg (a blood thinner) and Celexa 10 mg (an antidepressant) sitting on the resident's bedside tray table. Resident R1 was sound asleep, and the Licensed Practical Nurse (LPN) Employee E1 who prepared the medication was at the nurse's station. During an interview on 10/01/24, at the time of the observation, Registered…

    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 · E2024-06-18 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide the necessary assistance to maintain grooming and personal hygiene for five of 19 residents (Residents R2, R5, R15, R16, and R22). Findings include: A facility policy entitled, A.M. Care (Morning Care), dated 8/09/23, indicated that the purpose of a.m. care was to: refresh the resident; provide cleanliness, comfort, and neatness; prepare the resident for breakfast; assess the resident's condition; assess the resident's needs; and promote psychosocial well-being. Resident R15's clinical record revealed an admission date of 3/15/21, with diagnoses including stroke affecting his/her left side, lack of coordination, urinary incontinence, blindness, and dementia. A care plan entitled self-care deficit indicated that he/she required extensive assistance (resident involved, staff provide weight bearing support) of two staff members for grooming, hygiene, and dressing. Observation on 6/15/24, at 1:10 p.m. revealed Resident R15…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-18 · 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain sanitary food service operations for one of one kitchens. Findings include: Review of facility policy entitled, Dish Machine Setup, last reviewed 8/09/2023, indicated that the procedure of checking and documenting temperatures on the appropriate form was to occur at all meals. The policy and procedure also identified that the High Temp dish machine wash temperature ranges should be 150 degrees Fahrenheit (F) to 160 degrees F and that the final rinse temperatures should be at least 180 degrees F and up to 194 degrees F to ensure proper sanitization. Upon observation of the dish machine on 6/15/2024, at 3:30 p.m. it was confirmed that the dish machine was a hot water temperature machine. Review of the dish machine temperature logs revealed that for the month of May 2024, out of 93 temperatures documented there were 73 temperatures in the range of 160 -170 degrees F and all below the required 180 degrees F. For the month of June 2024, out of 42 temperatures…

    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 · D2024-06-18 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of resident council minutes, and resident and staff interviews, it was determined that the facility failed to respond to resident concerns identified during resident council minutes for three of three months reviewed (March, April, and May 2024). Findings include: Review of the March 2024 Resident Council Meeting Minutes revealed: lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included using chewing tobacco in resident room, main dining room doors being locked, and staff call bell response times. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of facility Grievance Concerns dated 3/27/24, revealed Resident Council concerns were documented and corrective actions included reviewing tobacco policy with resident, education provided about resident safety while dining room construction is completed, and reported to nursing staff and nurse aid supervisor to discuss and educate staff on call bell response times. Concern forms lacked evidence 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-18 · 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 clinical records, observations, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each residents' physical, mental, and psychosocial needs. The facility failed to obtain physician orders for smoking for one of 19 residents reviewed (Resident R9). Findings include: Resident's R9's clinical record revealed an admission date of 4/01/10, with diagnoses of multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves), heart problems, anxiety, and bipolar (disorder with mood swings ranging from depressive lows to manic highs). Review of a facility policy entitled, Tobacco and Vaping Policy, dated 8/09/23, indicated that the purpose to ensure that the facility meets Federal and State regulations and guidelines regarding smoking under the home's safety rules and under applicable Federal and State laws and rules unless not medically advisable as documented in the resident's medical record by the attending…

    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 · D2024-06-18 · 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 review of clinical records, facility policy and staff interviews, it was determined that the facility failed to assure that medication regimens were free of potentially unnecessary medications for two of 19 residents reviewed (Residents R38 and R69). Findings include: A facility policy entitled Drug Regimen Review dated 8/09/23, indicated that: the facility shall maintain copies of completed pharmacy reports; that the prescriber/licensed designee shall act upon the Drug Regimen Review findings/recommendation in a timely manner of 21 days or less; and that the prescriber/licensed designee shall document on the drug regimen review form whether he/she disagrees with the recommendations, and provide a brief clinical rationale if no change is to be made. Resident R38's clinical record revealed an admission date of 10/1019, with diagnoses including alcohol abuse with alcoholic-induced psychotic disorder, dementia with behavioral disturbances, and stroke. Resident R38's clinical record contained a Physician's Communication Form dated 4/26/24. The clinical record lacked copies 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-06 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that professional licensed staff implemented life-saving interventions regarding residents requiring cardiopulmonary resuscitation (CPR - emergency life-saving procedure that is done when the heart stops beating and when performed immediately can double or triple chances of survival after cardiac arrest) as required by the facility. Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to direct the overall operation of the facility's activities in accordance with current Federal, State, and local laws and regulations, guidelines and standards, as directed by Company policy. The NHA also has duties and responsibilities to develop systems and standards for the delivery of health care services and is accountable for assuring the delivery of high-quality care, including adherence to professional standards of care in accordance with State,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-06 · 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 facility policy and clinical records and staff interview, it was determined that the facility failed to follow physician's orders for laboratory work for one of five residents reviewed (Resident R45). Findings include: Review of facility policy entitled RN Supervisor Guide dated 8/9/23, indicated that laboratory orders are entered into PCC (Point Click Care) and that staff is to write down the physician initials, order date, and labs in the RN Lab Book. Review of Resident R45's clinical record revealed an admission date of 1/24/24, with diagnoses that included dysphagia (difficulty swallowing), atrial flutter (abnormal heart rhythm causing your heart to beat too fast), and kidney failure. Review of Resident R45's clinical record revealed a physician's order dated 2/19/24, at 13:17 for a CBC (complete blood count), Iron, and Ferritin level one time only for anemia. Further review of Resident R45's clinical record revealed that the laboratory work that was collected and completed on 2/20/24, lacked evidence of the Iron and Ferritin level being completed as ordered.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-22 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for seven of 10 residents reviewed (Residents R1, R2, R7, R8, R10, R11, and R12). Findings include: Review of facility policy entitled Care Plans dated 8/9/23, indicated The care plan will be reviewed, evaluated, and updated at a minimum of every 90 - days. Resident R1's clinical record revealed an admission date of 4/23/23, with diagnoses that included Multiple Sclerosis (MS - a degenerative disease that affects the nerves disrupting the signals between the brain and body), Traumatic Brain Injury (TBI - injury to the brain caused by trauma), and Epilepsy (neurological disorder resulting in seizures). Review of Resident R1's comprehensive care plan revealed that of the eight care plans present, eight had an outstanding target date (a date that the resident's care plan must be updated by) of 7/23/23. Resident R2's clinical record revealed an admission date of 11/18/23, with diagnoses that included Metabolic Encephalopathy…

    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 · D2023-11-22 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to falls for one of three residents reviewed (Resident R1). Findings include: Review of facility policy dated 8/9/23, entitled Fall Prevention and Fall Management indicated that When a fall occurs the following will be followed by the nurse - Complete a QA Incident Report and Document the assessment of the resident and any orders / interventions in the medical record. Resident R1's clinical record revealed an admission date of 4/23/23, with diagnoses that included Multiple Sclerosis (MS - a degenerative disease that affects the nerves disrupting the signals between the brain and body), Traumatic Brain Injury (TBI - injury to the brain caused by trauma), and Epilepsy (neurological disorder resulting in seizures). Investigation into Resident R1's fall history revealed there was no evidence in Resident R1's clinical record of a fall occurring on or around 10/13/2023. Interview with Director of Nursing (DON) 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 — the official record, unedited, may be distressing

    Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure the food preparation area was maintained in a safe and sanitary manner in the main kitchen. Findings include: Observations conducted on 9/19/2023, at approximately 10:00 a.m. of the main kitchen revealed two fans over the meal prep area and one fan facing the meal prep area with a thick layer of dust and a fuzzy substance. Review of the maintenance logs revealed the last time the main kitchen fans were cleaned was on 8/1/2023. Interview conducted with the Kitchen Manager on 9/19/2023, at the time of the observation confirmed that the two fans over the meal prep area and the one fan facing the meal prep area had a thick layer of dust and a fuzzy substance. 28 Pa. Code 211.6(c)(f) Dietary services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-05 · 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 a review of facility policy, observations, and staff interviews, it was determined that the facility failed to adhere to proper infection control practices related to COVID-19 for six employees observed on Units East and [NAME] (Employees E2, E3, E4, E5, E6, and E7). Findings include: Review of facility policy, COVID-19 Infection Prevention and Control Measures and Management, dated 5/10/23, revealed Responding to a newly identified SARS-CoV-2 infected HCP or resident: Source control (well-fitted face mask) should be worn by all individuals. Source control should be worn by everyone in the facility-facemasks will be offered to visitors if they do not wear their own mask or face covering. Observations on 9/03/23, at approximately 5:00 p.m. revealed Nurse Aide (NA) Employee E2 walking down the hallway towards Unit E with no mask on. Further observations during a tour of the facility with Registered Nurse (RN) Supervisor Employee E1, revealed Licensed Practical Nurse (LPN) Employee E3 of Unit E, LPN Employee E4 of Unit E, and NA Employee E5 of Unit E, without masks on. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-05 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 review of facility and clinical records, resident and staff interviews, and observations, it was determined that the facility failed to provide a bath/shower in accordance with resident preferences for two of two residents reviewed (Residents R1, R2). Findings include: Review of the Bath (Shower) policy, dated 8/2018, revealed The purpose of Bath (Shower) is to cleanse and refresh the resident. Frequency of Baths/Showers are based on resident preference. During an interview with Resident R1 on 8/30/23, at 1:05 p.m. it was indicated that a bed bath was preferred over a shower. Resident R1 further indicated his/her hair gets wet during a shower and a bath was not offered by staff anymore. He/she indicated he/she has only had a few bed baths in the past months, and it was a struggle to get the ones he/she did get. Resident R1 was observed with curled set hair. A review of clinical documentation revealed Resident R1 received a bed bath on 8/09/23, 8/30/23, and 9/02/23. No further bath/shower documentation was noted within the thirty-day period between 8/06/23 and 9/05/23.…

    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 · D2023-09-05 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and staff interview, it was determined that the facility failed to ensure that the required nurse staffing information was posted on a daily basis. Findings include: Observations on 9/03/23, at 5:20 p.m. revealed that the daily staffing posting was not publicly posted in the facility. During an interview at the time of the observation, the lack of the posting was confirmed by the Registered Nurse Supervisor Employee E1. 28 Pa. Code 211.12 (c) Nursing services

    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

$25,853 in federal fines across 1 penalty.

  • $25,853 — penalty dated 2024-03-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
BABIAK, JAIMEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
BEERBOWER, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
EBERLIN, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
LIN, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
SHUTTLEWORTH, JONATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
MILLCREEK MANOROrganizationADP OF THE SNFsince 06/01/2025
ROSCOE, BRANDONIndividualADP OF THE SNFsince 06/01/2025

CMS files one row per role, so the 12 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$9.4M
Net patient revenuemost recent cost report
-8.4%
Operating marginrevenue minus expenses
$2.0M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 91%Medicare 3%Other / private 7%

About 91% 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 $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$295per resident / day
operating cost
$8,972per month
≈ monthly operating cost
$272per 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 395728. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-29, 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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