Havencrest Rehabilitation And Healthcare Center
1277 Country Club Road, Monongahela, PA 15063 · For profit - Limited Liability company · 48 certified beds · (724) 258-3000 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 26% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 13.6% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.9% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.2% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.4% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.3% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 15.1% | 17.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 17.1% | 20.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.2% | 25.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.2% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 92.3% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.3% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.1% | 9.5% | 12.0% | typical |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 34.4% 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 32 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 0.43 therapist hours per resident per day in 2026Q1 — more than 72% 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
| 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 | 59.1%CMS range 49.6–70.7 | 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 | 9.9%CMS range 7.0–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 34.4% | 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 | 46.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 28.1% | 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 | 100.0% | 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 | not 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 discharge | 95.2% | 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 | 5.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.8–15.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.76 | 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 48 beds and averages 43.8 residents a day — about 91% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.26 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 3.38 hrs/resident/day on weekends vs 3.73 on weekdays — 9% thinner on weekends. RN hours go from 1.46 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-06-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document treatments for one of five residents (Resident R1).Findings include: Review of the facility policy, Charting and Documentation dated 3/11/26, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 3/7/26, included diagnoses of malnutrition (body does not get 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 · F2026-02-11 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 out of 12 months (February 2025 through February 2026).Findings include:During an interview on 2/8/26, at 10:28 a.m., the Dietary Supervisor Employee E10 stated that she is not yet certified and that the Dietician comes in Wednesday's and sometimes Tuesday or Friday depending in the need.During an interview on 2/8/26, at 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide documented evidence that Dietary Supervisor Employee E10 met the qualifications for the position of Food Service Director.Pa Code: 201.18(e)(6) Management.
- Potential for harm · Fcited before2026-02-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined that the facility failed to properly store food products in the reach in cooler which created the potential for cross contamination (Main Kitchen). Findings include:During an observation on 2/8/26, from 10:30 a.m., through 10:54 a.m., the following was observed:Large bowl of pudding in cooler, uncovered and undatedTwo large bags of lettuce were liquified and spoiledA container of broth was in cooler with no date of being made or expiration. During an interview on 2/8/26, at 10:54 a.m., the Dietary Supervisor Employee E10 confirmed that the facility failed to properly store food products in the reach in cooler which created the potential for cross contamination (Main Kitchen). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(3) Management.
- Potential for harm · Fdisputed · IDR2026-02-11 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on a review of observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen. Findings include: During an observation on 2/8/26, at 10:30 a.m., the dish machine wash cycle is required to reach at least 160 degrees, the machine was reaching 150 then immediately dropped to 145 degrees when ran three times. During an observation on 2/9/26, at 9:48 a.m., of the dish machine cycling, the Corporate Dietician Employee E11 stated that the wash thermometer is nonfunctioning, and the facility must use temperature strips, which did identify the was cycle reaching 180 degrees and confirmed the facility was not aware that the dishwasher was inoperable until the morning of 2/9/26.28 Pa Code:201.14(a) Responsibility of Licensee
- Potential for harm · E2026-02-11 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing halls (front hall and back hall).Findings include:During an observation on 2/11/2026 from 10:20 a.m., through 11:10 a.m., the following was identified: room [ROOM NUMBER]- floor was soiled with black marks and debrisroom [ROOM NUMBER] - bed b had debris under bed and the wall behind headboard was scraped and chipped paintrooms [ROOM NUMBERS] shared bathrooms had bubbling paint behind toilet wall with missing paintrooms [ROOM NUMBERS] had soiled floors with debris and black marksroom [ROOM NUMBER]-with 4 beds had soiled privacy curtains, walls with chipped paint and the floors under the fall mats had not been cleaned with black marksroom [ROOM NUMBER]- had soiled privacy curtains, the wall behind D bed had bubbled paint and tape over wall, the mattress on the bed was very soiled with white substances and appeared…
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 before2026-02-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to provide appropriate treatment and care for one of two residents (Resident R33).Findings include: Review of facility policy Transportation, Resident Appointments dated 10/8/25, indicated a member of the nursing staff or Social Services will accompany a resident to an appointment when they cannot go alone based on the following:Elopement riskPoor judgement making skillsExhibit wandering behaviorsCognitive impairment/poor decision making in residents who ambulate with use of a wheelchairNeed assistance with ADL's (activities of daily living) A review of the clinical record indicated Resident R33 was admitted to the facility on [DATE] with diagnoses that included dementia, Alzheimer's disease, muscle weakness, and syncope (fainting). A review of the Minimum Data Set (MDS) Resident Assessment and Care Screening dated 8/29/25 indicated the diagnoses remained current. Resident R33 was cognitively impaired and 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.
- Potential for harm · D2026-02-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of professional standards of practice, facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer that developed into a Stage IV pressure ulcer (severe full thickness wound extending to exposed muscle, tendon or bone often with slough, eschar and tunneling) to the coccyx extending to bilateral buttocks and a denuded tissues (tissue that had been stripped of the first layer of skin) of the scrotum for one of three residents reviewed (Resident R4). Findings include:Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting…
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 · D2026-01-22 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of two residents (Resident R100).Findings include:Review of the facility policy Abuse Investigation and Reporting reviewed on 10/8/25, indicated all reports of resident abuse, neglect, exploitation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The individual conducting the investigation will, at a minimum: c). Interview the person(s) reporting the incident; and i.) Interview other residents to whom the accused employee provided care or services.Review of the clinical record indicated Resident R100 was re-admitted to the facility on [DATE], with diagnoses that included high blood pressure, depression, and chronic pain.Review of facility records indicated on 1/1/26, Resident R100 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.
- Potential for harm · E2025-09-30 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and Infection Control Preventionist (ICP) credential review, it was determined that in addition to the role of the Director of Nursing (DON), the DON was also the ICP since 09/08/25.Findings include:Review of the DON job description indicated the DON is responsible for the planning, organization, development, and direction of the overall operation of the Nursing Department. The DON is to maintain compliance with federal, state and local regulations.Review of the Infection Preventionist job description indicated the ICP primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with current federal, state and local standards, guidelines and regulations that govern such programs and as directed by the Administrator to ensure effective infection prevention and control program is maintained at all times.During an interview on 9/30/25, at 9:08 a.m., the Director of Nursing (DON) stated that the facility just put a Licensed Practical Nurse in place of Infection Control and that she is…
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 · E2025-09-30 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of job descriptions and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.Findings include:Review of the Infection Preventionist job description indicated the ICP primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with current federal, state and local standards, guidelines and regulations that govern such programs and as directed by the Administrator to ensure effective infection prevention and control program is maintained at all times. During an interview on 9/30/25, at 9:08 a.m., the Director of Nursing (DON) stated that the facility just put a Licensed Practical Nurse in place of Infection Control and that she is trained but that she, the Interim DON has been acting as the Infection Control Nurse at this time. The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing…
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 15 citations
- Potential for harm · Ecited before2025-08-21 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide an ongoing vital signs and neurological assessment after an unwitnessed fall for three of five residents (Resident R1, R2 and R3). Findings include:Review of the facility policy Managing Falls and Fall Risk dated 4/2/25, indicated all residents experiencing a fall will have an evaluation to identify the root cause of the fall and documentation by the nursing staff should include vital signs and if unwitnessed neuro checks completed. An evaluation of injuries and appropriate first aide if necessary. Staff are to observe for delayed complications for 48 hours and document findings. Review of the facility Fall care path indicated that vital signs including neuro checks if unwitnessed fall should continue for 24 to 72 hours.Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included lung disease, heart fibrillation 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 · Fcited before2025-02-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 a review of facility policies, observations and staff interview it was determined that the facility failed to properly store, label and date food products and failed to ensure that chemical sanitation levels were at appropriate levels to sanitize dishware and utensils in the main kitchen which created the potential for food borne illness. Findings Include: Review of the facility policy Food Storage last reviewed 3/4/24, indicated that metal and plastic containers must have a tight fitted lid and be accurately labeled with no scoops inside of any food container. Review of the facility policy Quaternary Ammonium last reviewed on 3/4/24, indicated the use if this solution for sanitation of pots, pans and utensils indicated a standard mixture of 200 PPM for adequate sanitation. During an observation in the Main Kitchen the following was identified: The milk cooler temperature indicated that the temperature in the cooler was 41 degrees, there was no thermometer identified inside the cooler to make certain the milk temperature was accurate. A large plastic clear container…
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 · E2025-02-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — the official record, unedited, may be distressing
Based on a observation and staff interview, it was determined that the facility failed to provide a safe environment for residents in one of two nursing units (Back Hall Nursing Unit). Findings include: During an observation on 2/18/25, at 10:53 a.m. the Utility Room door was noted not to have a locking mechanism. Within the room, a full sharps container without a lid was present on a small table. During an interview on 2/18/25, at 10:58 a.m. Registered Nurse Employee E5 confirmed that the utility room was a Sharps Room, and further confirmed that without a locking mechanism, the full sharps container posed a safety risk to residents. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide a safe environment for residents in one of two nursing units. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 201.29(a)(c)(d) Resident rights.
- Potential for harm · E2025-02-20 · tag F0699 — patternProvide care or services that was trauma informed and/or culturally competent.
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, clinical records, and staff interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of three residents (Resident R13 and R26). Findings include: Review of the facility policy, Behavioral Assessment, Intervention and Monitoring dated 3/4/24, indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of the clinical record revealed that Resident R13 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated…
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 · E2025-02-20 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to make certain that medications and biologicals were properly stored and/or disposed of in one of one medication rooms and one of two medication carts (Long Hall medication cart). Findings include: Review of the U.S. FDA approved prescribing information for Aplisol (solution used in tuberculosis screening) dated 11/2013, indicated that in-use vials must be used within 30 days. Review of the U.S. FDA approved prescribing information for Lantus (a type of insulin) dated 05/2019, indicated that in-use vials must be used within 28 days. Review of the U.S. FDA approved prescribing information for Prednisolone Sodium Phosphate (lubricant eye drops) dated 04/2023, indicated that in-use vials must be used within 28 days. Review of the facility policy Medication Storage in the Facility dated 3/4/24, indicated that medication and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or…
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 · E2025-02-20 · 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 review of facility policy, manufacturers' instructions, observation, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during glucometer usage for five of six residents (Residents R90, R92, R95, R11, and R16). Findings Include: Review of the facility policy Blood Sampling - Capillary (Finger Sticks) dated 3/4/24, indicated in the list of equipment and supplies needed was a Disinfected blood glucose meter. The policy further indicated that after usage: Following the manufacturer's instructions, clean and disinfect reusable equipment after each use. Review of the Evencare G3 (glucometer) manufacturer's instructions dated 2016, indicated, The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. During an observation 2/19/25, at 4:04 p.m., Licensed Practical Nurse (LPN) Employee E2 removed the glucometer from the medication cart drawer, did not…
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 · E2025-02-20 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Abuse and Neglect Prevention for two of ten staff members (Employee E8 and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on Abuse and Neglect Prevention. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have Abuse and Neglect Prevention in-service education between 9/10/23, and 9/10/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have Abuse and Neglect Prevention in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training 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 · E2025-02-20 · tag F0945 — failed to train staff on abuse prevention — patternInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of ten staff members (Employee E6, E9, E11, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI program. Nurse Aide (NA) Employee E6 had a hire date of 1/19/23, failed to have infection control in-service education between 1/19/24, and 1/19/25. NA Employee E9 had a hire date of 10/30/21, failed to have infection control in-service education between 10/30/23, and 10/30/24. Registered Nurse Employee E11 had a hire date of 12/2/21, failed to have infection control in-service education between 12/2/23, and 12/2/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have…
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 · E2025-02-20 · 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 — an excerpt from the official record, may be distressing
Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees E8 and E9). Finding include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, received approximately 6.00 hours of in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, received approximately 3.75 hours of in-service education between 10/30/23, and 10/30/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff did not have documentation of 12 hours of in-service education. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-26 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven residents reviewed (Residents R9, R10, R24, and R33). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-26 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of 12 residents reviewed (Resident R43). Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with last reviewed on 3/6/23, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents. A review of the clinical record indicated that Resident R43 was admitted to the facility on [DATE], with diagnoses that included ESRD (the kidneys permanently fail to work), cancer, and dependence on renal dialysis. A review of the Minimum Data Set (MDS -…
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 · C2025-02-20 · tag F0942 — widespreadEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of ten staff members (Employee E7, E9, E11, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on Resident Rights. Nurse Aide (NA) Employee E7 had a hire date of 1/19/23, failed to have Resident Rights in-service education between 1/19/24, and 1/19/25. NA Employee E9 had a hire date of 10/30/21, failed to have Resident Rights in-service education between 10/30/23, and 10/30/24. Registered Nurse Employee E11 had a hire date of 12/2/21, failed to have Resident Rights in-service education between 12/2/23, and 12/2/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have Resident Rights…
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 · B2025-02-20 · tag F0941 — patternDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of ten staff members (Employee E8 and E9). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the effective communication. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have effective communication in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, failed to have effective communication in-service education between 10/30/23, and 10/30/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on the effective…
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 · B2025-02-20 · tag F0944 — patternConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for four of ten staff members (Employee E8, E9, E11, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI program. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have QAPI in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, failed to have QAPI in-service education between 10/30/23, and 10/30/24. Registered Nurse Employee E11 had a hire date of 12/2/21, failed to have QAPI in-service education between 12/2/23, and 12/2/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have QAPI…
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 · B2025-02-20 · tag F0949 — failed to train staff on dementia and abuse — patternProvide behavior health training consistent with the requirements and as determined by a facility assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for three of ten staff members (Employee E8, E9, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on behavioral health. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have behavioral health in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, failed to have behavioral health in-service education between 10/30/23, and 10/30/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have behavioral health in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant…
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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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.
Part of a chain
This home belongs to CORE HEALTHCARE — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.1 | -0.1 vs chain |
| Health inspection | 2 of 5 | 1.9 | +0.1 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 2 of 5 | 3.7 | -1.7 vs chain |
The other 6 homes this chain runs (chain average 2.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| G2 TBD HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 04/24/2025 |
| CAPITAL FINANCE LLC | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/24/2025 |
| EISEN, JOSHUA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/24/2025 |
| RAINTREE CONSULTING GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/24/2025 |
| PATTISON, JULIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/24/2025 |
| VIOLAGO, MARTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/24/2025 |
CMS files one row per role, so the 11 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 $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 395633. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, 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.