Brookline Nursing And Rehab
2 Manor Boulevard, Mifflintown, PA 17059 · For profit - Limited Liability company · 85 certified beds · (717) 436-2178 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.3% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.4% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 45.8% | 10.8% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.4% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.0% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.6% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.2% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.6% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.8% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.0% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.45 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.14 | 1.18 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.2% 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 101 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 106 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.2%CMS range 39.4–57.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 8.3–15.8 | 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 | 67.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.8% | 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 | 53.8% | 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 | 97.7% | 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 | 100.0% | 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 | 97.0% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 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 | 7.2%CMS range 4.0–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 85 beds and averages 81.3 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.42 hrs/resident/day on weekends vs 3.73 on weekdays — 8% thinner on weekends. RN hours go from 0.58 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Ecited before2026-02-27 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 5, dietary manager, on February 24, 2026, at 10:20 AM revealed the following: Shelves in a cupboard that held drink pitchers adjacent to the food preparation sink were flaking and/or peeling. A large white pipe going into the ceiling near a corner of the kitchen had an accumulation of black-colored dust around it. The wall behind the refrigerators that held tray carts had an accumulation of dust on it. A baseball sized area of peeling paint on the ceiling above a food prep area. Two dry goods storage rooms contained a large gap surrounding the interior perimeter of the room where the ceiling meets the wall. Cobwebs were also observed in the area. The wall area behind the dishwasher had an accumulation of a black substance on the wall. The wall under the stainless-steel table to the right of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to store indwelling urinary catheter equipment in a manner to prevent the potential for infection for one of one resident reviewed for catheter concerns (Resident 9).Findings include: Clinical record review for Resident 9 revealed that his diagnoses included urinary retention (inability of the bladder to empty completely after urination). Review of Resident 9's active physician orders revealed instructions for staff to change a Foley catheter (flexible tubing inserted through the penis into the bladder to drain urine) as needed for obstruction or dislodgement, and every thirty days for routine care of the indwelling urinary catheter. An active physician order instructed staff to place a leg bag (smaller urinary collection bag secured by straps onto the leg underneath clothing) on Resident 9 in the morning and a drainage bag (larger bag used to contain a larger amount of urine that is hung below the bladder on an item such as the side of the bed) for Resident 9…
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 · D2026-02-27 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview it was determined that the facility failed to identify and monitor the medical symptoms that warranted the use of an antipsychotic medication and monitor for potential adverse consequences of antipsychotic medication use for one of five residents reviewed for potentially unnecessary medication (Resident 9).Findings include: Clinical record review for Resident 9 revealed active physician orders (dated January 9, 2026) for admission to the skilled care facility for diagnoses of: Major depressive disorder (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems)PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event)Suicidal attemptCKD (chronic kidney disease, loss of the kidney(s)' ability to filter waste and excess fluid from the blood)Vascular dementia (decreased blood flow to the brain resulting in loss of memory and cognition) Progress note documentation from the facility'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.
- Potential for harm · D2026-02-27 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, review of facility documentation, and staff interview it was determined that the facility failed to provide written notice of transfer to the resident representative for three of six residents reviewed (Residents 5, 9, and 12) and written notice of the facility bed-hold policy for two of six residents reviewed for hospitalization (Residents 9 and 12).Findings include: Clinical record review for Resident 5 revealed the resident had an emergency contact listed. Nursing documentation for Resident 5 dated December 16, 2025, at 9:36 AM revealed the resident had a change in condition and the licensed practical nurse (LPN) evaluated the resident. Nursing documentation for Resident 5 dated December 16, 2025, at 10:19 AM revealed that a message was left for the responsible party and son. Nursing documentation for Resident 5 dated December 16, 2025, at 10:45 AM revealed that EMS (emergency medical services) arrived and care was transferred to EMS. Nursing documentation for Resident 5 dated December 16, 2025, at 5:00 PM revealed that the resident was 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 · D2026-02-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility failed to ensure an assessment accurately reflected the resident's status for one of 18 residents reviewed (Resident 9).Findings include: Clinical record review for Resident 9 revealed psychiatry progress note documentation dated [DATE], that Resident 9 was a military veteran and his wife died three weeks before the assessment. Diagnoses listed by the practitioner included PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event). An active physician's order dated [DATE], admitted Resident 9 to skilled care for diagnoses that included PTSD. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated [DATE], revealed that staff coded the MDS item for PTSD incorrectly as that Resident 9 did not have PTSD. Interview with the Director of Nursing 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 · D2026-02-27 · 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 and staff interview it was determined that the facility failed to develop and implement a comprehensive, person-centered, trauma-informed care plan to meet a resident's mental and psychosocial needs for one of 18 residents reviewed (Resident 9). Findings include: Clinical record review for Resident 9 revealed nursing documentation dated [DATE], at 9:42 AM that Resident 9 was noted in his bed with a cord around his neck. Resident stated that he wanted to get staff's attention, so he decided to wrap it around his neck. Resident 9 then started with paranoid thoughts and stated that his daughter killed his wife and shot her in the chest. He stated that, (acquaintances' surname) was also in on it to help cover it up. Resident 9 continued with paranoid thoughts on how his daughter killed his wife and, .wants to try and kill him so she can get his pension and get all of his money. Resident 9 left the topic of conversation easily and was noted with scattered thought processes. Resident 9…
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 · D2026-02-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and staff and family interview, it was determined that the facility failed to ensure assistance with activities of daily living for a dependent resident for one of one resident reviewed for activities of daily living concerns (Resident 66).Findings include: Interview with Resident 66's daughter on February 24, 2026, at 11:15 AM revealed that she believed that her father's fingernails were long, that his hair was long, and that she was upset by how he looked during her visit on February 12, 2026. Review of a plan of care developed by the facility on December 11, 2025, to address Resident 66's self-care deficits with activities of daily living (ADL) revealed that Resident 66 was dependent on staff for showering/bathing and personal hygiene needs. Observation of Resident 66 on February 25, 2026, at 8:50 AM revealed that his hair was cut short. Resident 66 stated that he was on his way to the therapy department where he was going to shave. Interview with Resident 66 on February 25, 2026, at 9:12 AM indicated that the barber cut his hair that…
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 before2026-02-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care for non-invasive ventilation consistent with professional standards of practice and develop a comprehensive and person-centered care plan for one of two residents reviewed (Resident 5) and maintain respiratory related equipment supplies in a safe and sanitary manor in two of two dining rooms observed (main dining room and restorative dining room). Findings include: Review of the facility policy titled CPAP (continuous positive airway pressure)/BiPAP (bilevel positive airway pressure) Support, revealed preparation for use included, in part, reviewing the physician's order to determine the oxygen concentration and flow and the PEEP (positive end expiratory pressure). Further review of the policy included a section on documentation that noted, in part, that mode and settings for the device should be documented in 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.
- Potential for harm · D2026-02-27 · tag F0697 — failed to manage pain — isolatedProvide 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 review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications and pain parameters for one of one resident reviewed for pain (Resident 3).Findings include: Clinical record review for Resident 3 revealed a diagnosis list that included pain in unspecified shoulder and myalgia (muscle pain). Resident 3's care plan revealed the resident has pain related to the medical history. An intervention included pain medications per physician orders. Review of the current physician orders for Resident 3 revealed the following medications for pain: Tramadol (a pain medication used to treat moderate to moderate severe pain) HCl oral tablet 50 milligrams (mg) give one tablet by mouth every four hours as needed for moderate to severe pain AND give one tablet by mouth two times a day for moderate to severe pain dated December 3, 2025, at 4:45 PM. Acetaminophen (Tylenol, a medication used to treat mild pain and reduce fever) tablet 325 mg give two…
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 · D2026-02-27 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident received pneumococcal immunizations unless refused or clinically contraindicated for one of five residents reviewed for immunization concerns (Resident 12).Findings include: The facility policy entitled, Pneumococcal Vaccine, last reviewed without changes on November 20, 2025, revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. For residents who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in 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.
Show the remaining 20 citations
- Potential for harm · D2026-01-22 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate and report allegations of abuse and neglect for two of three residents reviewed (Residents CR1 and CR2). Findings include: The policy entitled, Abuse Investigation and Reporting, last reviewed without changes on November 20, 2025, indicated that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The policy indicated that if an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported the administrator will assign the investigation to an appropriate individual. All alleged violations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-21 · tag F0744 — failed to care for residents with dementia — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 18, 55, and 61). Findings include: Clinical record review for Resident 18 revealed the facility admitted him on July 13, 2018. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added on October 3, 2022. A review of Resident 18's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated February 9, 2025, indicated that the facility assessed Resident 18 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 18's care plan revealed that there was no indication that the facility had developed and implemented a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 4, Dietary Manager, on March 18, 2025, at 10:00 AM revealed the following: There was a large hole observed in the wall of the dishwashing area. Two wall tiles adjacent to the hole had fallen off the wall onto the ground. There was an extensive build-up of dust on the appliance that Employee 4 referred to as the air handler. A wall-mounted first aid kit held burn spray that expired in 2021 and eye wash that expired in 2023. A smaller pantry area located in the hallway outside of the main kitchen held hand wipes that expired in October 2023. The pantry area also held a bottled drink that Employee 4 reported was used for colonoscopy (an exam where a flexible medical device is inserted into the colon to assess for abnormalities) preps. This…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-21 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 1, 2, and 3). Findings include: During a meeting with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 1, 2, and 3 (nurse aides). Interview with the Nursing Home Administrator and Director of Nursing on March 21, 2025, at 10:55 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training. 28 Pa. Code 201.19 (7) Personnel policies and procedures
- Potential for harm · D2025-03-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, it was determined that the facility failed to provide a reasonable accommodation of needs in response to call bell activations for one of two nursing units observed (Unit 2; Residents 14 and 57). Findings include: Clinical record review for Resident 57 revealed a diagnosis list that included dementia (a loss of cognitive function that is caused by the permanent damage or death of the brain's nerve cells, or neurons). Resident 57's annual Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 14, 2025, noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment. An interview with Resident 57 on March 18, 2025, at 11:31 AM revealed he was sitting in a chair next to the bed. The resident reported concerns that staff do not answer the call bell activations timely and sometimes take an hour or longer to respond and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one of two nursing units (Unit 3; Residents 51 and 73). Findings include: Observation of the Unit 3 Nursing Unit on the following dates and times revealed the following: On March 18, 2025, at 1:54 PM the drywall was marred behind Resident 51's head of the bed and their recliner. On March 18, 2025, at 2:24 PM the drywall was marred behind Resident 73's head of the bed. The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM. 28 Pa. Code 201.18(b)(3) Management
- Potential for harm · D2025-03-21 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for two of five residents reviewed for hospitalizations (Residents 11 and 70). Findings include: Clinical record review revealed that Resident 11 was transferred to the hospital on March 17, 2025, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 21, 2025, at 9:10 AM. Clinical record review revealed that Resident 70 was transferred to the hospital on March 5, 2025, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon…
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 · D2025-03-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services to promote bladder continence for one of one resident reviewed for incontinence (Resident 31). Findings include: The policy entitled Urinary Continence and Incontinence- Assessment and Management, last reviewed on November 16, 2024, indicates as part of the initial and ongoing resident assessments, the nursing staff and physician will screen residents for information related to urinary incontinence. As part of the facility's assessment, nursing staff will seek and document details related to continence (relevant details include voiding patterns, associated pain or discomfort, and types of incontinence). The nursing staff and physician will identify risk factors for becoming incontinent, or for worsening of the resident's current incontinence. The evaluation will include a review for medications that might affect…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of one resident reviewed (Resident 19). Findings include: Clinical record review for Resident 19 revealed a diagnosis list that included acute and chronic respiratory failure (a condition that makes it difficult to breathe) with hypercapnia (elevated levels of carbon dioxide in the blood), chronic obstructive pulmonary disease (COPD, a lung disease that causes inflammation and restricted air flow into and out of the lungs), acute and chronic respiratory failure with hypoxia (low oxygen levels in the body), and pulmonary embolism (a blood clot in the lungs). Current physician orders for Resident 19 revealed an order dated September 17, 2024, for supplemental oxygen at five liters per minute (LPM) via nasal cannula (medical tubing that delivers supplemental oxygen to the nose) every shift to maintain pulse ox (pulse oximeter; a non-invasive measure of the body's oxygen level) greater than 90…
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 · D2025-03-21 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment for one of three residents reviewed for accident hazards (Resident 72). Findings include: Observation of Resident 72's room on March 18, 2025, at 2:02 PM revealed that there was a left one-quarter side rail observed on the bed. Clinical record review for Resident 72 revealed that the facility completed a side rail assessment, review of potential risks, and obtained consent on February 7, 2025. The facility also completed a side rail entrapment evaluation on February 7, 2025, which revealed that the facility assessed zone six (between the end of the enabler device and the side of the headboard). There was no documentation that the facility assessed the risk for entrapment posed in zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), three (between the edge of the mattress and inside of the rail, and four (between the top of the compressed mattress and the bottom of the rail at the end…
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 · E2024-03-22 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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 clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to initiate their abuse policy and thoroughly investigate incidents to rule out the potential for abuse for one of two residents reviewed (Resident 64). Findings include: The policy entitled Abuse Investigation and Reporting, last reviewed on November 17, 2023, indicates that if an incident, suspected incident, or resident abuse is reported, the Administrator will assign the investigation to an appropriate individual. The individual conducting the investigation will review the residents medical record to determine events leading up to the incident, interview the person reporting the incident, and interview any witnesses to the incident. Witness reports will be obtained in writing. Either the witness will write his or her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him or her sign and date it. Review of Resident 64's clinical record revealed nursing documentation dated January 4,…
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 · E2024-03-22 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding bowel protocol medication administration for two of two residents reviewed (Residents 43 and 77) and regarding the use of a cardiac pacemaker for one of one resident reviewed with a pacemaker (Resident 26). Findings include: Clinical record review for Resident 43 revealed a current care plan that noted bowel/bladder elimination alteration and constipation related to immobility and medications. Some interventions included: Administer medications per physician order, bowel protocol as needed; report bowel movements and report abnormalities; and report signs and symptoms of constipation such as abdominal cramping, diarrhea, nausea/vomiting, no bowel movement for three days. Clinical record review for Resident 43 revealed the following physician orders to promote bowel movements: Milk of Magnesia Suspension 400 mg (milligrams) per 5 ml (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents) Give 30 ml by mouth as…
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 · E2024-03-22 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the appropriate physician ordered enteral nutrition for one of one resident reviewed for tube feeding concerns (Resident 27). Findings include: Clinical record review for Resident 27 revealed an active physician's order dated January 14, 2023, that instructed staff to provide enteral feeding (provision of food and fluids via the gastrointestinal tract, e.g., directly into the stomach, not through the mouth) of Isosource 1.5, 65 ml (milliliters) continuously with 250 ml water every six hours. An active physician's order dated January 26, 2023, instructed staff to clear the feeding pump and document the amount given for both water and feeding every shift. Observation of Resident 27 on March 19, 2024, at 1:29 PM revealed Isosource 1.5 liquid nutrition infusing via a pump set at a rate of 65 ml per hour and a stop setting at 520 ml. A bag of water was also attached to the pump system. Observation of Resident 27 on March 21, 2024, at 3:21 PM with Employee 3 (licensed…
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 · D2024-03-22 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding advance directives for two of three residents reviewed (Residents 26 and 32). Findings include: Review of Resident 32's clinical record revealed that the facility admitted her on February 11, 2024. Review of a POLST (Physician Orders for Life Sustaining Treatment, a document for specific medical orders to be honored by health care workers during a medical crisis) form signed by Resident 32's responsible party on February 13, 2024, indicated that he wished for Resident 32 to have full treatment, including CPR (cardiopulmonary resuscitation). A physician's order dated February 14, 2024, indicated that Resident 32 was a DNR (Do Not Resuscitate, not to perform cardiopulmonary resuscitation if breathing stops). There was no documented evidence in Resident 32's clinical record to indicate she or her responsible party's advance directive (written instruction, such…
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 · D2024-03-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, clinical record review, review of facility documentation, and staff and a resident's family interview, it was determined that the facility failed to implement interventions to prevent falls and/or injuries for one of seven residents reviewed for falls (Resident 57) and failed to prevent a potential accident hazard at the facility's main entrance. Findings include: Clinical record review for Resident 57 revealed a current physician's order for staff to apply a sensor pad alarm to her chair and check the placement and function every shift for safety. Observation of Resident 57 on March 19, 2024, at 12:38 PM and March 20, 2024, at 12:10 PM revealed that she was in her recliner and her chair alarm was placed on her wheelchair: Concurrent interviews during each date and time with Resident 57's family confirmed the observations. Review of the facility's after-hours entrance procedure indicated that the front main entrance door is open from 5:00 AM to 9:00 PM. Observation of the front main entrance lobby on March 22, 2024, at 8:40 AM revealed no staff within…
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 before2024-03-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 clinical record review, observation, and staff interview, it was determined that the facility failed to administer supplemental oxygen as prescribed by the physician for one of one resident reviewed for oxygen concerns (Resident 27). Findings include: Clinical record review for Resident 27 revealed an active physician's order dated January 12, 2023, that instructed staff to administer supplement oxygen via a nasal cannula (NC, flexible tubing with small prongs at one end inserted into the nostrils for the application of supplemental oxygen) at three liters per minute (3 l/m). Observation of Resident 27 on March 19, 2024, at 1:37 PM revealed the application of supplemental oxygen via a NC and room oxygen concentrator (medical device used to concentrate the oxygen available in room air to administer oxygen-enriched supply back to the resident). The administration setting on the room concentrator was two liters per minute (2 l/m). Observation of Resident 27 on March 21, 2024, at 3:02 PM again revealed the application of supplemental oxygen via a NC and room concentrator at a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-22 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to ensure necessary behavioral health treatments were initiated for one of one resident reviewed (Resident 64). Findings include: Review of Resident 64's clinical record from August 9, 2023, until October 24, 2023, revealed multiple documented behaviors including holding on to a females arm tightly and rubbing it, rubbing females backs, pulling fire alarms, cornering females, and not letting them pass, inappropriate sexual behaviors, wanting females to sit on his lap, and following females around the facility. Review of a psychiatric evaluation dated October 24, 2023, indicated a new order for Resident 64 to start Prozac (used to treat some mood disorders) 10 mg (milligrams) every day. The new order for Prozac was noted by nursing staff on October 30, 2023, but never added to Resident 64's medication regimen until November 23, 2023, a month after it was ordered. Interview with the Director of Nursing on March 21, 2024, at 2:15 PM, confirmed the above findings for Resident 64. 28 Pa. Code…
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 · D2024-03-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 45). Findings include: The facility's medication error rate was 5.56 percent based on 36 medication opportunities with two medication errors. Observation of Resident 45's medication administration pass on March 22, 2024, at 9:15 AM revealed Employee 1, licensed practical nurse, prepared the resident's medications prior to administration. Employee 1 proceeded to open the medication capsules and pour the contents into a medication administration cup. Employee 1 mixed the contents with applesauce and then administered the medications to the resident. Clinical record review for Resident 45 revealed a current physician's order to administer Tolterodine Tartrate ER (extended release) capsule (a medication used to treat an overactive bladder) 4 milligrams one time a day. The instructions on the medication package provided by the pharmacy instructed to swallow whole and do not crush or chew. An interview with…
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 · D2024-03-22 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of select facility policies, observations, and staff and resident family interviews, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for one of two nursing units. (200 Nursing Unit, Resident 57). Findings Include: Review of Facility Policy: Foods Brought by Family/Visitors, last reviewed without changes on November 17, 2023, revealed that the facility will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Facility staff will discard perishable foods on or before the use by date. Nursing and/or food service staff will discard any food any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). Observation of Resident 57's room on March 19, 2024, at 12:39 PM revealed that she had a personal refrigerator. The temperature monitoring log was dated April 2023, and completed through April 21, 2023. There was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-03-21 · tag F0623 — widespreadProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for four of five residents reviewed (Residents 11, 39, 48, and 70). Findings include: Clinical record review for Resident 11 revealed that they were transferred to the hospital on March 17, 2025, after a change in their condition. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, and contact, email, and address information for the Office of the State Long-Term…
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
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BROOKLINE HEALTH HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2024 |
| BROOKLINE 101 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 04/01/2024 |
| PALMER GARDENS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 30% | since 04/01/2024 |
| FELDHEIM, ISRAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 50% | since 04/01/2024 |
| KRAUSZ, ARON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 04/01/2024 |
| MAGYAR, SHARON | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2024 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 395418. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, 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.