Delaware Valley Skilled Nursing & Rehabilitation C
111 Rivers Edge Drive, Matamoras, PA 18336 · For profit - Corporation · 70 certified beds · (570) 491-1010 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2024
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.0% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.6% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.5% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.2% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 28.2% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.7% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.7% | 25.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.7% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.3% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 70.6% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.6% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.7% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.56 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.16 | 1.18 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.4% 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 347 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.1% 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 160 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 0.61 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.4%CMS range 41.7–52.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.2%CMS range 9.9–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 87.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.0%CMS range 3.9–8.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 70 beds and averages 61.5 residents a day — about 88% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Weekend coverage: total nurse staffing is 3.25 hrs/resident/day on weekends vs 3.73 on weekdays — 13% thinner on weekends. RN hours go from 0.80 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · E2026-03-13 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record and select facility policy review and staff interview, it was determined that the facility failed to provide effective pain management and administer pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication as prescribed for two resident out of 15 residents reviewed (Resident 10 and Resident 2). Findings include: A review of the facility's policy entitled Pain Management Policy with a policy review date of May 13, 2025, indicated that the physician will order appropriate nonpharmacological and medical interventions to address the individual's pain. A clinical record review revealed Resident 10 was admitted to the facility on February17, 2025, with diagnoses that include Spina Bifida, (a neural tube (the embryonic structure that develops into the brain and the spinal cord that forms the central nervous system) defect that occurs when the fetus's spine does not close completely during early development causing symptoms of incontinence, loss…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure Licensed Practical Nurses (LPNs) administering intravenous (IV) therapy via a peripherally inserted central catheter (PICC) possessed the required education, competency, and supervision for one of 15 residents reviewed (Resident 63).Findings include: A review of the Pennsylvania Code, Title 49, Chapter 21.145 (Functions of the Licensed Practical Nurse), revealed that an LPN must perform nursing functions based on appropriate knowledge, skill, and competency, and may administer IV therapy only after completing the required IV therapy education and training. The regulation further requires that IV therapy be performed under the direction and supervision of a licensed professional nurse (RN) or other authorized health care provider. The regulation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to provide necessary care and services to ensure appropriate assessment and ongoing monitoring of a surgical wound in accordance with professional standards of practice for one of fifteen residents reviewed (Resident 2). Findings include: A review of the facility policy titled Skin Policy, last reviewed May 13, 2025, indicated that upon admission, licensed nursing staff complete a head-to-toe skin assessment and document all findings in the nursing clinical assessment. The policy indicated staff document all skin impairments and wounds in the Skin Assessment Section of the admission Screener and on the skin assessment forms, to include measurements (length, width, and depth, including tunneling or undermining, which refers to channels or areas of tissue destruction under the skin), and a detailed description of the wound bed (the visible tissue within the wound), including the presence of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and implement nutritional interventions for one resident out of 15 residents reviewed (Resident 47).Findings include: A review of a facility policy entitled Resident Heights and Weight Policy last reviewed by the facility May13, 2025, indicated residents will be weighed upon admission to facility and on day two after admission. After the second day weight, all newly admitted residents will be weighed weekly for four weeks and then on a monthly basis unless otherwise specified. The resident weights will be recorded in the electronic medical record. Reweighs will be obtained for any residents whose weight fluctuates by plus or minus five pounds (lbs.) for those over 100 lbs. and plus or minus three pounds for those weighing less than 100 pounds. The licensed nurse will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to implement procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one of 15 residents reviewed (Resident 10). Findings include: A review of the facility policy titled Controlled Substances, last reviewed March 13, 2025, revealed the facility will comply with all applicable laws, regulations, and requirements related to the handling, storage, disposal, and documentation of Schedule II and other controlled medications (Schedule II controlled medications are drugs regulated by the federal government that have accepted medical use but a high potential for abuse and dependence, requiring strict tracking and accountability). A clinical record review revealed Resident 10 was admitted to the facility on February17, 2025, with diagnoses that include Spina Bifida, (a birth defect in which the spinal column does not close completely, which may result in paralysis, loss of sensation, and incontinence) and Major Depressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 clinical record review, review of facility policy, and staff interview, it was determined the facility failed to ensure that psychotropic (medications that affect mood, behavior, or mental processes) medications were used in accordance with regulatory requirements by failing to implement and document non-pharmacological interventions and failing to ensure appropriate duration and rationale for as-needed (PRN) psychotropic medication orders for two of 15 residents reviewed (Residents 6 and 63).Findings include: A review of the policy entitled, Behavioral Assessment, Intervention, and Monitoring last reviewed May 13, 2025, indicated the facility will provide and residents will receive behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy statement indicated that the facility would adhere to regulatory requirements related to the use of medications to manage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy and clinical record review, observation, and staff interview, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of infection for one of 15 residents reviewed (Resident 3).Findings include: According to the Centers for Disease Control and Prevention (CDC) (2024), Enhanced Barrier Precautions are measures to reduce the spread of multi-drug-resistant organisms (MDRO) (bacteria that are resistant to multiple antibiotics and are difficult to treat) in nursing homes. Enhanced Barrier Precautions require gown and glove use during resident care activities that have been demonstrated to result in transfer of MDROs to the hands and clothing of healthcare personnel. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The CDC (2024) identifies residents who are considered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-13 · tag F0940 — failed to train staff — isolatedDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of employee personnel records, review of facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely manage a peripherally inserted central catheter (PICC line) for 1 resident (Resident 63) of 15 residents reviewed.Findings include:Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The facility must use the facility assessment, which is an evaluation the facility conducts to identify the resident population served to determine the amount and types of training necessary to ensure staff competencies meet the needs of the residents as identified in their care plans and the facility assessment. A review of the facility policies entitled Medication Administration. Policy 5.09 Intravenous…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-01 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of clinical records, facility policy, controlled drug shift count records, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed intravenous (IV) antibiotic for one of 16 sampled residents (Resident 34), and maintain accurate controlled drug shift count documentation on one of two medication carts reviewed, thereby failing to promote accountability and medication safety. Finding included: A review of a facility policy entitled Medication Availability last reviewed by the facility May 2024, indicated a procedure if a medication is not available the facility's procedure required staff to check the Cubex (is an automated medication dispensing machine system used for healthcare management that helps deter delayed medication administration and improve inventory management for healthcare facilities). If the prescribed medication was not available, staff were to contact the pharmacy for delivery status and request STAT (immediate) delivery and place a call into the satellite…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility documentation, it was determined the facility failed to develop a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, mental, and psychosocial needs for one of 25 sampled residents (Resident 37), who expressed suicidal ideations. Findings include: A review of the clinical record revealed that Resident 37 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily functioning). A progress note dated April 2, 2025, at 11:45 a.m., documented that the resident expressed suicidal ideation, stating to a staff member that she wanted to kill herself. Following this, the resident was evaluated by the facility's social services department and placed on every 15-minute checks. However, a review of the resident's comprehensive care plan, in effect as of the survey ending May 1,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2025-05-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to review and revise the comprehensive care plan to reflect a significant change in condition related to weight loss for one of 16 residents sampled (Resident 2). Findings include: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily functioning). A review of the resident's documented weights revealed the following: On November 4, 2024, Resident 2 weighed 203.3 pounds. On December 4, 2024, the resident weighed 189.5 pounds, which represented a 6.8% loss of body weight in 30 days. A nutrition progress note dated December 6, 2024, indicated the registered dietitian (RD) assessed Resident 2 due to the identified weight loss and continued to recommend interventions. However, the resident's current care plan, which was originally developed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-08 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, clinical records and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for bowel protocol to promote normal bowel activity for one resident (Resident 42), failed to provide consistent application of prescribed therapeutic devices and preventative measures, skin sleeves, TED stockings, and heel floats for three residents (Residents 42, 46, and 48, and failed to constantly document food/fluid intakes to accurately monitor and timely identify changes in a resident's condition for one resident out of 16 sampled (Resident 24). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-08 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policies, and staff interviews, it was determined that the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and failed to develop/revise and implement effective nutrition management interventions to prevent further significant weight loss and dehydration for one resident out of six residents sampled with weight loss (Residents 43). Findings included: A review of facility policy titled Resident Heights and Weights, last reviewed by the facility on May 24, 2024, indicated that the facility would utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss in residents. Resident weights were recorded in the electronic health record and a reweight was obtained for any residents whose weight fluctuated by plus (+) or minus (-) five pounds (lbs.) for those over 100 lbs. and plus or minus three pounds for those weighing less than 100 lbs. Any resident being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-08 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of select facility policy, meal delivery times, snack listing and resident and staff interviews, it was determined that the facility failed to routinely offer evening snacks to four of four residents interviewed (Residents 4, 3, 40, and 27) and failed to offer a nourishing snack to all residents when the dinner meal is greater than 14 hours before breakfast is served. Findings include: Review of the facility policy titled HS Snack Policy last reviewed by the facility on May 23, 2024, indicated that all residents, unless medically contraindicated, will be provided a nourishing snack at bedtime daily. A nourishing snack means items from the basic food groups, whether singly or in combination with each other. During a group meeting with residents conducted on August 7, 2024, at 10:00 a.m. four out of four residents (Residents 4, 3, 40, and 27) in attendance, stated that they are not offered snacks during the evening hours before bed as desired. Resident 40 stated I've been here for several months, and they haven't offered snacks. Resident 27 stated that the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility reports, observations and staff and resident interviews it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening and the development of pressure sores for one resident out of 16 residents sampled (Resident 43). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-08 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and resident and staff interview, it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of one sampled receiving hemodialysis (Resident 218). Findings include: According to the National Kidney Foundation, patients receiving hemodialysis( a life saving treament for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) should keep emergency care supplies on hand. A review of the resident's clinical record revealed that Resident 218 was admitted to the facility on [DATE], with diagnoses to include end stage renal disease, and dependence on renal dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Resident 218's clinical record indicated he was receiving hemodialysis through an Ash Cath(type of vascular access hemodialysis catheter) in his left arm (dialysis access…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-08 · tag F0791 — failed to provide routine dental services — isolatedProvide 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, payor source data, and staff interview, it was determined that the facility failed to promptly refer a resident with a broken bridge for dental services for one Medicaid payor source resident (Resident 4) and failed to provide dental services for a resident with poor dentition and high-risk diagnosis (heart valve) with Medicaid as payor source (Resident 24). Findings included: Review of the clinical record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses to include diverticulitis (inflammation or infection in one or more small pouches in the digestive tract), and hypertension (high blood pressure-force of blood against the artery walls is too high). Review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated May 19, 2024, revealed that Resident 4 was moderately cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status, which assesses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-08 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
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 select facility policy and reports, clinical records and resident and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of 16 sampled (Resident 41). Findings include: Review of the facility policy entitled Quality Assurance and Performance Improvement Plan last reviewed by the facility on May 23, 2024, revealed that the facility will put in place systems to monitor care and services, drawing from data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also will include tracking, investigating, and monitoring adverse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and medication records, and resident and staff interview it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 16 residents sampled (Resident 14). Findings included: A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses, of diabetes, hypertension, and H. pylori infection (Helicobacter pylori, bacteria that infects the stomach). A review of the resident's March 2024 Medication Administration Record (MAR) revealed that on March 23, 2024, the resident was prescribed Bismuth Subsalicylate (an over-the-counter medication to treat diarrhea, heartburn, nausea, and upset stomach) 525 mg, two tablets every 6 hours for treatment of H. pylori for 14 days. The medication was scheduled for administration at 6 AM, 12 PM, 6 PM, and 12 AM. There was no evidence that the medication was administered to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy and investigative reports, and staff interview, it was determined that the facility neglected to provide one resident with the necessary care and services to prevent injury and maintain physical health out of 16 sampled. (Resident 4). Findings include: A review of the facility's abuse prohibition policy provided on March 27, 2024, revealed that it the policy of the facility to protect their residents from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. A review of Resident 4's clinical record revealed admission to the facility on June 14, 2022, with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), osteoarthritis, and heart disease. Resident 4's plan of care, last revised by the facility October 30, 2022, indicated that the resident has an ADL (activity of daily living)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, select investigative reports, and clinical records, and staff interview, it was determined that the facility failed to ensure that one resident was free from misappropriation of resident property, narcotic opioid medications, for two residents out of 17 residents sampled (Resident 16 and 17). Findings included: A review of the facility's abuse prohibition policy provided on March 27, 2024, revealed that it the policy of the facility to protect their residents from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. Misappropriation is the deliberate misplacement, exploitation, or wrongful, (temporary or permanent) use of a residents' belongings or funds without the resident's consent. A review of the clinical record revealed that Resident 16 was admitted to the facility on [DATE], with diagnoses of hypertension and diabetes. The resident had a physician order initially dated January 26, 2024, for Oxycodone (a narcotic opioid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses fully evaluated a resident's status after an unwitnessed fall for one resident (Resident CR1) out of 14 residents reviewed. Findings included: According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
CMS ownership filings flag an owner of this facility as a private-equity firm. That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.
- PA TENANT 3 MEZZ, LLC — private equity · 100.00% share · 5% Or Greater Indirect Ownership Interest
- EAZ OPERATING COMPANY, LLC — private equity · 35.00% share · 5% Or Greater Indirect Ownership Interest
- HELP FOR THE KIDS, LLC — private equity · 35.00% share · 5% Or Greater Indirect Ownership Interest
- 2020 GSR DYNASTY LLC — private equity · 30.00% share · 5% Or Greater Indirect Ownership Interest
Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PA TENANT 3 HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/28/2023 |
| EAZ OPERATING COMPANY, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/28/2023 |
| HELP FOR THE KIDS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/28/2023 |
| PA TENANT 3 MEZZ HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/28/2023 |
| PA TENANT 3 MEZZ, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/28/2023 |
| KEEFER, SUSAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 03/28/2023 |
| KELLY, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 03/28/2023 |
| GEORGE S. REPCHICK 2020 FAMILY DYNASTY TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 03/28/2023 |
| OXFORD FINANCE LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 03/28/2023 |
| SENIOR HEALTH CARE SOLUTIONS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| ESTELL, KAITLIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/27/2022 |
| FALCO, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/15/2023 |
| FEDORKA, KELLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| HANRAHAN, STEPANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| HENTSCHEL, KATHLEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/29/2021 |
| LEDERER, BRENDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2022 |
| MALLOY, CATHERINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/29/2024 |
| PALOVITZ, TRACY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/12/2021 |
| PASCAL, SANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2024 |
| ROGERS, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/24/2024 |
| VERDE, RACHEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2020 |
| REPCHICK, GEORGE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/07/2025 |
CMS files one row per role, so the 41 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $239K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 396148. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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.