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Fulton County Medical Center

214 Peach Orchard Road, McConnellsburg, PA 17233 · Non profit - Other · 67 certified beds · (717) 485-3155 Medicare & Medicaid certified

Call the home — (717) 485-3155 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0607) — most recent Dec 20242 actual-harm citations$16,801 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0607) — most recent Dec 2024
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,801 in federal fines (most recent 2024-12-03)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

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) 5 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
525 Fulton Dr · (717) 485-3850 · Call to confirm hours
Pharmacy
214 Peach Orchard Rd · (717) 485-3622 · Call to confirm hours
Grocery
182 Buchanan Trl · (717) 987-9592 · Call to confirm hours
Park
664 Lions Park Dr · Typically dawn to dusk
Place of worship
954 Lincoln Way W · (717) 494-5880

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

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 fell from 4 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.

Overall rating3★
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 increased20.1%16.8%15.4%worse
Long-stay residents who lose too much weight6.1%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder4.4%0.7%0.9%worse
Long-stay residents with a urinary tract infection2.1%1.5%2.0%typical
Long-stay residents with depressive symptoms5.0%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.2%3.1%3.3%typical
Long-stay residents whose ability to walk worsened23.4%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication29.0%20.0%18.9%worse
Long-stay residents given the seasonal flu vaccine98.0%93.5%95.3%typical
Long-stay residents with pressure ulcers11.1%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control19.1%25.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table22.0%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Long-stay hospitalizations per 1,000 resident days1.191.621.67better
Long-stay outpatient ER visits per 1,000 resident days2.321.181.80worse

§ 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.

0.15U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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 identifiednot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.72
RN hours/ resident / day
1.08
LPN hours/ resident / day
2.62
Aide hours/ resident / day
4.42
Total nurse hours/ resident / day
0.50
RN hoursweekends
26.8%
Total nursing turnover
10.0%
RN turnover

How full it usually is: this home is certified for 67 beds and averages 49.1 residents a day — about 73% occupied, or roughly 18 beds typically open. It usually has some room. 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 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 is at or above 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 3.87 hrs/resident/day on weekends vs 4.65 on weekdays — 17% thinner on weekends. RN hours go from 0.81 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-04-17)
9
at the previous standard inspection (2024-05-01)

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

Inspection deficiencies

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

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2024-12-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policies, investigative reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of two residents reviewed (Resident 1), resulting in a dislocated shoulder. Findings include: The facility's policy regarding abuse and neglect, dated March 14, 2024, indicated that every resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; and involuntary seclusion. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. A nursing note for Resident 1, dated November 17, 2024, at 12:11 p.m., revealed that Resident 1 was exhibiting increased behaviors and requested something for pain. A nursing note for Resident 1, dated November 18, 2024, at 3:30 p.m., revealed that she had multiple scattered bruises…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-12-03 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that allegations of possible abuse were reported timely to the Nursing Home Administrator for one of two residents reviewed (Resident 1) resulting in pain and a delay in treatment for a dislocated shoulder. Findings include: The facility's abuse policy, dated March 14, 2024, indicated that staff were to report any allegation or suspicion of abuse immediately to their supervisor, and if the perpetrator was an employee, he/she would be suspended pending investigation to ensure protection of the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. A nursing note for Resident 1, dated November 17, 2024, at 12:11 p.m., revealed that Resident 1 was exhibiting increased behaviors and requested something for pain. A 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-17 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 25 residents reviewed (Resident 8). Findings include: A facility policy regarding administering medication, dated August March 6, 2025, revealed that staff were to administer medications that were ordered by the physician; to ensure the right resident received the right medication at the right time. Medication given to a resident shall be prescribed by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 25, 2025, indicated that the resident was cognitively intact, required assistance from staff for care needs, had diagnoses that included Type I diabetes (unable to produce insulin needed to regulate blood sugar), and was administered insulin (medication to lower blood sugar). Physician's orders for Resident 8, dated January 10, 2025, included an order for the resident to receive Insulin…

    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 · E2025-04-17 · tag F0761 — failed to label and store drugs safely — pattern
    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 observations and staff interviews, it was determined that the facility failed to discard expired medical supplies in two of two medication rooms reviewed (Overly Meadows and [NAME] Trails). Findings include: Observations in the Overly Meadows medication room on [DATE], at 11:22 a.m. revealed that there were six 24 gauge angiocatheters (small teflon tubing inserted into the vein to administer fluids or medication) that expired [DATE]; one 18 gauge needle expired on [DATE]; and one 25 vial box of 20 cc's each normal saline solution that expired on [DATE]. Interview with Licensed Practical Nurse 1 on [DATE], at 11:26 a.m. confirmed that the above angiocatheters, needles and syringe should not have been in circulation in the medication room if they were expired. Observations in the [NAME] Trails medication room on [DATE], at 12:20 p.m. revealed that there were nine 24 gauge IV catheters that expired [DATE]; two 20 gauge IV catheters that expired [DATE]; twenty- seven 22 gauge IV catheters, 26 that expired…

    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 · D2025-04-17 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital for two of 25 residents reviewed (Residents 8, 23). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 25, 2025, indicated that the resident was cognitively intact, was understood, could understand others, and required assistance from staff for care needs. A review of the medical record revealed that Resident 8 had his sister listed as the person to be notified in an emergency. A nursing note, dated September 23, 2024, at 3:45 p.m., revealed that Resident 8 reported he was not himself, was shaking, and was confused. He had developed a skin rash to creases in skin folds, behind his…

    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 before2025-04-17 · 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update the care plan for one of 25 residents reviewed (Resident 37). Findings include: The facility's policy regarding care plans, dated March 6, 2025, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated September 7, 2024, indicated that the resident was cognitively intact, usually understood and understands, required assistance from staff for his daily care needs, and had diagnoses that included end-stage renal disease. A care plan, dated August 7, 2023, revealed that Resident 37 had a hemodialysis catheter (a type of catheter used for vascular access during hemodialysis treatment that is typically inserted into a large vein, such as the jugular or femoral vein, to facilitate the removal and return 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of hospice contracts, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 25 residents reviewed (Residents 27, 36) who received hospice services. Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated March 9, 2018, revealed that it was the responsibility of the hospice to provide information to the skilled nursing facility to include plan of care, Benefit of Election form (a form used to formally enroll a patient in hospice care), advance directives, certification and recertification of terminal illness (a form signed by the resident's hospice physician and specific to each patient), names and contact info of hospice personnel, instructions for access of hospice 24 hour on-call system, hospice medication information, hospice and attending orders. The facility's policy regarding hospice 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during wound care for one of 25 residents reviewed (Resident 23). Findings include: The facility's policy regarding hand hygiene, dated March 6, 2025, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 30, 2024, indicated that the resident was cognitively intact, was understood, could understand others, required assistance from staff for care needs, and had diagnoses that included left arm hematoma (blood clot) and sepsis (a medical emergency in response to an infection). Physician's orders for Resident 23, dated April 11, 2025, included an order to cleanse the left arm with normal saline (salt water)…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in the facility's laundry area. Findings include: A facility policy regarding chemical dispensing, dated August March 6, 2025, indicated that the automatic dispensing system was to ensure safe dispensing of chemicals for the laundry department. The automatic liquid dispensing system would dispense chemicals for the recommended amounts of detergent per the chemical manufacturer. Observations in the laundry department on April 18, 2025, at 12:50 p.m. revealed that the laundry area had two washing machines. There was a five-gallon bucket on the floor and a smaller bucket on the counter with blue liquid in it. Interview with Environmental Service Staff (ESS) 3 at the time of the observation revealed that the second washing machine's automatic feeder was not working and was not adding the detergent to the washing machine. She had to open the five-gallon bucket on the floor that had…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-03 · 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 clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. Review of the facility's investigation for Resident 1, dated November 19, 2024, revealed that on November 14, 2024, Resident 1 was yelling and resisting care. A witness statement by Nurse Aide 1, dated November 20, 2024, revealed that she observed Nurse Aide 2 force Resident 1's left arm above her head, back against the bed, and then force the arm back to a normal position while putting on her deodorant. Nurse Aide 1 stated that she immediately observed a deformity in Resident 1's left shoulder and that the resident was complaining of pain, as well…

    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 · F2024-05-01 · 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 — an excerpt from the official record, may be distressing

    Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food safety, dated March 13, 2024, indicated that food needs to be stored in clear plastic containers covered with a lid, labeled with the name of the food, dated with a prepared date, and a use by date. The item can also be wrapped, dated, and labeled so that the food item was air tight. Observations in the walk-in freezer on April 29, 2024, at 9:45 a.m. revealed opened and unlabeled bags of corn with peppers and onions, green beans, hamburger patties, and hash browns that were not in a clear plastic container. Interview with the Dietary Manager at the time revealed that staff should be using a label maker to put a sticker on the food item when a new container is opened. Observations in the walk-in refrigerator on April 29, 2024, at 9:45 a.m. revealed that there was a five-pound plastic container of cottage cheese opened and unlabeled; 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 date of correction
  • Potential for harm · E2024-05-01 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop a comprehensive care plan related to the use of anticoagulant medication for one of 27 residents reviewed (Resident 40). Findings include: The facility's policy regarding care plans, dated March 13, 2024, indicated that an individualized comprehensive care plan will be developed by the interdisciplinary team within 21 days of admission for each resident. The care plan will include focus issues, problems and needs (social, emotional, psychological, physical, behavioral, rehabilitation, cultural, spiritual, nutritional, leisure, prevention of decline in condition, ect.) that have been identified through resident involvement, direct observation, coordination of discipline observations and assessment. As each issue, problem or need is added to the care plan, a date will be recorded with the issue to document the specific time when the issue was identified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's…

    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 11 citations
  • Potential for harm · Ecited before2024-05-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of 27 residents reviewed (Residents 25, 30, 39, 40). Findings include: A facility policy regarding plans of care, dated March 13, 2024, revealed that the care plan will be reviewed and revised by the interdisciplinary team at least quarterly, or more often as changes occur, by nursing staff to include new orders, resident's individual preferences, effective interventions, etc. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 19, 2024, revealed that the resident was understood and could understand, could ambulate (walk) on the unit independently, and had diagnoses that included non-traumatic brain dysfunction (a brain injury not caused by external physical force or trauma exerted on the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for one of 27 residents reviewed (Resident 28). Findings include: The facility's self-administration of medications policy, dated March 13, 2024, indicated that if a resident desired to self-administer medications they would require a physician's order. The facility's medication administration policy, dated March 13, 2024, indicated that the nurse must stay with the resident until medication is taken. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated January 30, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff with care, had impaired movement of one side of upper and lower extremities, and had diagnoses that included hemiplegia (the inability to move one side of the body). Current…

    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 before2024-05-01 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 27 residents reviewed (Resident 25). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 29, 2024, indicated that the resident was understood and could understand, was cognitively intact, and independent for care. A care plan for Resident 25, dated January 24, 2024, indicated that the physician must be notified of all refusals of medication. Physician's orders for Resident 25, dated January 25, 2024, included an order for the resident to receive Cefdinir (a medication that destroys bacteria) twice a day for 11 doses. Physician's orders for Resident 25, dated November 15, 2023, included an order for Miacalcin nasal spray (a medication to treat the thinning of bones) 1 unit daily at 8:00 a.m. A review of the electronic medication administration record (MAR), dated January, February, and March…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate treatment and services were provided to prevent the development of pressure ulcers for one of 27 residents reviewed (Resident 39). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated February 26, 2024, revealed that the resident was usually understood, could usually understands others, was frequently incontinent of bowel and bladder, had diagnoses that included Parkinson's disease and dementia, and had one Stage 2 pressure injury (a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) that was not present upon admission. A nursing note for Resident 39, dated February 19, 2024, revealed that the resident was admitted from another nursing care facility and that the resident had a small red mark to his right posterior thigh from his brief. A care plan for Resident 39, dated February 19, 2024, revealed that the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 27 residents reviewed (Residents 40, 42). Findings include: The facility's policy on wheelchairs, dated March 13, 2024, indicated that all wheelchairs being utilized for transport purposes should be equipped with leg rests and utilized when residents are being transported. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated March 19, 2024, revealed that the resident had clear speech, understood, could understand, was severely cognitively impaired, required assistance from staff for daily care needs, used a wheelchair, and had diagnoses that included Alzheimer's disease. Observation of Resident 40 on April 29, 2024, at 11:17 a.m. revealed that the resident was sitting in a wheelchair while being transported to her room from the dining/community room by Licensed Practical Nurse…

    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 · Dcited before2024-05-01 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of a list of nurse aides provided by the facility and the nurse aides' personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for two of five nurse aides reviewed (Nurse Aides 6, 7). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations were due between April 13, 2023, and June 6, 2023. However, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 6 and 7. Nurse Aide 6 had a hire date of April 13, 2021. Nurse Aide 6's personnel file revealed that she had a performance evaluation completed on December 15, 2023. However, there was no documented evidence that her annual performance evaluation was completed as required in April 2023. Nurse Aide 7 had a hire date of June 6, 2022. Nurse Aide 7's personnel file revealed that she had a performance evaluation completed on December 28, 2023.…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the survey ending June 28, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 1, 2024, identified repeated deficiencies related to notification of changes and nurse aide performance review. The facility's plans of correction for deficiencies regarding notification of changes in resident condition, cited during the survey ending June 28, 2023, revealed that the facility would…

    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 before2023-06-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified about a significant change in condition for one of 25 residents reviewed (Resident 22). Findings include: The facility's weight policy, dated March 14, 2023, indicated that a registered nurse (RN) assessment would be completed on significant weight changes, and the physician would be notified of the resident's change in physical condition. Review of Resident 22's clinical record revealed a weight on May 7, 2023, of 178 pounds and a weight on June 6, 2023, of 167 pounds, which indicated an 11-pound weight loss in 30 days. A nutritional assessment note written by the dietician for Resident 22, dated June 12, 2023, indicated that the resident had a significant weight loss of 6.18 percent in the past 30 days. A nursing note for Resident 22, dated June 13, 2023, revealed that a RN assessment was completed for significant weight loss. However, there was no documented evidence that the physican was notified of the resident's…

    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 before2023-06-28 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies, Pennsylvania laws and personnel records, as well as staff interviews, it was determined that the facility failed to ensure that Pennsylvania State Police background checks were completed for one of five employees reviewed (Registered Nurse 1). Findings include: The facility's policy regarding abuse, dated March 14, 2023, revealed that all new employees will have a criminal background check completed by the human resources department within 30 days of hire. Chapter 5, Section 502(a)(1) of Pennsylvania Act 169, dated December 18, 1996, indicates that a criminal history report is to be obtained from the State Police for all applicants. Section 501 defined State Police as The Pennsylvania State Police. Section 506 indicated that the facility could employ applicants on a provisional basis for a single period not to exceed 30 days if the applicant has applied for the Pennsylvania State Police criminal history record and the applicant provides a copy of the request form. The personnel file for Registered Nurse 1 revealed that she was hired on February 28, 2023,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen therapy as ordered by the physician for one of 25 residents reviewed (Resident 51). Findings include: The facility's policy regarding oxygen therapy, dated March 14, 2023, indicated that oxygen would be delivered at the proper liter flow rate as per physicians orders. A diagnosis record for Resident 51, dated June 21, 2023, revealed that the resident had diagnoses that included COPD (chronic obstructive pulmonary disease, a lung disease that makes it difficult to breathe). Physician's orders and the resident's care plan, dated June 21, 2023, revealed that the resident was to receive oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils). Observations of Resident 51 on June 26, 2023, at 11:23 a.m. and June 27, 2023, at 4:00 p.m. revealed that the resident was in bed with oxygen in use at a flow rate of 2.5 liters per minute and on June 28, 2023, at 8:08…

    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 · Dcited before2023-06-28 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on the hire dates for two of three nurse aides reviewed (Nurse Aides 3, 4). Findings include: Nurse aide performance evaluation records revealed that Nurse Aides 3 and 4 were each hired over one year ago and annual performance evaluations were not completed as follows: Nurse Aide 3's hire date was May 14, 2019, and had a performance evaluation completed on June 27, 2023; however, there was no documented evidence of a performance evaluation being completed for 2022. Nurse Aide 4's hire date was June 8, 2018, and had a performance evaluation completed on June 26, 2023; however, there was no documented evidence of a performance evaluation being completed for 2022. Interview with the Nursing Home Administrator on June 28, 2023, at 8:45 a.m. confirmed that Nurse Aides 3 and 4 did not have annual performance evaluations completed timely based on their hire dates. 28 Pa. Code 201.14(a) Responsibility 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.

    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

$16,801 in federal fines across 2 penalties.

  • $8,400 — penalty dated 2024-12-03
  • $8,401 — penalty dated 2024-12-03

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
MAKOSKY, MICHAELIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORsince 07/01/2018
STERN, DOUGLASIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/01/2024
ALEXANDER, SCOTTIndividualCORPORATE DIRECTORsince 01/01/2017
D'AMELIO, FRANKIndividualCORPORATE DIRECTORsince 01/01/2012
DANIELS, LISAIndividualCORPORATE DIRECTORsince 01/01/2018
FRAKER, SEANIndividualCORPORATE DIRECTORsince 01/01/2020
GRESS, TINAIndividualCORPORATE DIRECTORsince 01/01/2019
HANN, TIMOTHYIndividualCORPORATE DIRECTORsince 01/01/2015
MELLOTT, MARKIndividualCORPORATE DIRECTORsince 01/01/2017
PALMER, VIRGINIAIndividualCORPORATE DIRECTORsince 01/01/2015
SHIVES, PENELOPEIndividualCORPORATE DIRECTORsince 01/01/2015
SLEE, KIMBERLYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/07/2025
WRIGHT, MARYIndividualCORPORATE OFFICERsince 01/01/2018

CMS files one row per role, so the 17 rows in the source record cover these 13 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.

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 395387. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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