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Avalon Care Center

3410 W. Pittsburgh Rd, New Castle, PA 16101 · For profit - Limited Liability company · 84 certified beds · (724) 658-4781 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Feb 20241 immediate-jeopardy citation$19,888 in federal fines
Insights

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

Worth asking about
  • it has a citation for 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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $19,888 in federal fines (most recent 2025-04-29)
  • its independent health-inspection rating is low (2/5)
  • CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1112 S Mill St · (724) 658-4564 · Call to confirm hours
Pharmacy
734 E Washington St · (724) 654-3294 · Call to confirm hours
Grocery
440 E Long Ave · (724) 654-0444 · Call to confirm hours
Park
Dean Park0.4 mi
513 Taylor St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.7%16.8%15.4%better
Long-stay residents who lose too much weight5.2%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.7%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms2.0%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.7%3.1%3.3%worse
Long-stay residents whose ability to walk worsened7.4%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.7%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine82.6%93.5%95.3%worse
Long-stay residents with pressure ulcers6.5%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control20.4%25.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table20.4%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.7%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine74.1%68.7%79.4%typical
Short-stay residents rehospitalized after admission28.7%22.5%22.6%worse
Short-stay residents with an outpatient ER visit26.7%9.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.581.621.67typical
Long-stay outpatient ER visits per 1,000 resident days1.881.181.80typical

§ 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.

48.3% 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 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.3%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
77.8%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 77.8% 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 27 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.3%CMS range 37.6–59.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.5–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge77.8%56.6%Oct 2024–Sep 2025CMS 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 discharge63.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.3%50.0%Oct 2024–Sep 2025CMS 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 identified61.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.7–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.59
RN hours/ resident / day
0.82
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.28
Total nurse hours/ resident / day
0.42
RN hoursweekends
55.6%
Total nursing turnover
56.3%
RN turnover

How full it usually is: this home is certified for 84 beds and averages 75.9 residents a day — about 90% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 3.05 hrs/resident/day on weekends vs 3.37 on weekdays — 9% thinner on weekends. RN hours go from 0.66 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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

7
deficiencies at the latest standard inspection (2026-06-12)
6
at the previous standard inspection (2025-06-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, facility policy and documentation, and staff and resident interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of one residents reviewed who eloped from the facility (Resident R1). Findings include: Review of the facility policy entitled, Safety and supervision of residents, with a policy review date of 1/20/2025, revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our facility-oriented approach to safety address risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting process. Resident R1's clinical record revealed an admission date of 2/28/2025, with diagnoses 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2026-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility incident reports, facility documents, and staff interviews, it was determined that the facility failed to provide necessary precautionary measures to maintain resident safety and prevent injury during transport in a wheelchair resulting in harm of a fractured orbital bone (a bony cavity in the skull that houses and protects the eyeball) for one resident reviewed (Resident R1). Findings include: Review of facility policy entitled Abuse and Neglect dated 4/16/26, revealed Neglect.means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait and mobility, weakness, difficulty in walking, hypertension (high blood pressure), dysphagia (difficulty swallowing), and lack in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-02-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during a transfer, and resulted in actual harm when the resident received rib fractures that required medical treatment at a hospital for one of one residents reviewed (Resident R1). Findings include: Review of the facility policy, SRC-Safety-17.35 Transfers-ABC, dated 5/12/23, indicated to assist residents with movement from one surface to another .(1) verify resident's mobility needs .(3) determine the necessary amount of assistance needed in accordance with the plan of care. Review of the Job Description Professional CNA (Certified Nurse Assistant) revealed that the nurse aide will provide routine resident care and support services in accordance with established policies and procedures . Review of Resident R1's clinical record revealed an admission date of 1/18/24, with diagnoses 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, observations, and staff and resident interviews, it was determined that the facility failed to administer supplemental oxygen as ordered for one resident and promote cleanliness and prevent the spread of infection regarding respiratory care equipment for three of 25 residents reviewed (Residents R32, R53, and R72).Findings include:Review of facility policy entitled Oxygen Administration, dated 4/16/26, revealed Set the flow rate as ordered by physician; Oxygen shall be humidified as indicated by physician; Humidifier bottle shall be connected to the oxygen concentrator prior to setting flow rate.Review of facility policy entitled Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure [CPAP (therapy that keeps your airways open during sleep to treat sleep apnea and other breathing disorders) BiPAP (noninvasive device that helps people breathe by providing two levels of air pressure: higher when inhaling and lower when exhaling)] Support dated 4/16/26, revealed: Mask, nasal pillows, and tubing; clean daily by…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2026-06-12 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for four of 21 residents reviewed for showers/bathing (residents R2, R43, R53, and R77), and eight of 21 residents reviewed for call bell response times (Residents R21, R23, R29, R32, R42, R44, R65, and R66) Findings include:A Facility policy entitled Activities of Daily Living (ADL), Supporting dated 4/16/26, indicated that: residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2026-06-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to discard outdated insulin on two of four medication carts and failed to prevent the opportunity for unauthorized access of medications on one of four medication carts. Findings include: A facility policy entitled Storage of Medications dated [DATE], indicated discontinued, outdated, or deteriorated drugs or biologics are returned to the dispensing pharmacy or destroyed; and compartments (including drawers, carts) containing drugs and biologics are locked when not in use, and unlocked medication carts are not left unattended. A facility policy entitled Insulin Pen Storage Policy dated [DATE], indicated that a beyond-use dating label will be assigned to the cartridge (28 days or manufacturer's expiry, whichever is first), check the cartridge's insulin type and expiry before each use. Observation on [DATE], at 3:11 p.m. revealed that Building One Back Hall medication cart was located in the hallway…

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

    Pharmacy Service Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-06-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the hospice/facility agreement and clinical records, and staff interview, it was determined that the facility failed to maintain current information related to hospice services for one of four hospice residents reviewed (Resident R13). Findings include: Review of a hospice facility agreement dated 5/23/26, revealed the following:The Interdisciplinary Team with Nursing Facility representatives and the Nursing Facility Attending Physician shall review and revise the individualized Plan of Care as frequently as the resident/patient's condition requires, but no less frequently than every 15 calendar days.Hospice shall provide the Nursing Facility Designee with a copy of the most recent Plan of Care specific to each resident/patient.Nursing Facility and Hospice shall each prepare and maintain complete, accurate, and detailed clinical records concerning each resident/patient.All entries made for services provided hereunder are to be legible, clear, complete, and appropriately authenticated and dated in accordance with applicable policy and currently accepted standards…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-06-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety and failed to maintain sanitary conditions in one of two resident refrigerators (Building One). Findings include: Review of facility policy entitled Use and Storage of Food Brought to Residents By Visitors, dated 4/16/26, revealed that Visitors may bring food to our residents upon their request; Any food brought into the facility for onsite consumption must be in ready-to-eat form; Food or beverage in the original containers that is beyond the manufacturer's expiration date will be discarded by nursing staff. Observation on 6/10/26, at 10:50 a.m. of the building one refrigerator used for residents revealed two individual containers of yogurt with manufacturer's expiration dates of 5/28/26 and 5/31/26, and a brown sticky substance covering the shelf of the refrigerator. During an interview on 6/10/26, at the time of observation Registered Nurse Employee E5 confirmed the resident refrigerator in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-12 · tag F0848 — isolated
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of the facility's arbitration agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and/or resident representative and facility agree on the selection of an arbitrator and venue. Findings include: Upon review of the facility's arbitration agreement for who will conduct the arbitration, the arbitration agreement lacked evidence addressing that the selected venue would be convenient to both the resident and/or resident representative and the facility. During an interview on 6/12/26, at 11:20 a.m. Nursing Home Administrator confirmed the language of the arbitration agreement does not provide for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue that is convenient to both parties. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

    Administration Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records and facility policy, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during the administration of medications through a gastrostomy tube [G-tube (a surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach for individuals who cannot eat enough by mouth)] for one of five residents observed during medication administration (Resident R38).Findings include:A facility policy entitled Enhanced Barrier Precautions (EBP (infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms [MDROs] in healthcare settings) dated 4/16/26, indicated that EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply; and examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use…

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

    Infection Control Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-04-15 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of two buildings that residents reside (Building One). Findings include: No facility policy provided. Observations on 4/13/26, at approximately 11:00 a.m. revealed seven windows open with no screens throughout Building One. During the time of observations, the Maintenance Director confirmed that the facility did not have screens for any windows, including the seven windows that were observed open in the facility. Interviews with Residents R1, R2, and R3 on 4/13/26, at 11:45 a.m. through 12:20 p.m. revealed that a snake was observed in a resident's room and hallway of Building One the evening of 4/09/26. Resident R1 and R2 further indicated that the snake likely came in through an open window due to no screens in the window, allowing pests to enter freely. Interview with the Nursing Home Administrator (NHA) on 4/13/26, at 2:35 p.m. confirmed that a snake was in the building on 4/09/26, and the facility was unaware of how the snake…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to implement resident-directed care and treatment consistent with professional standards of practice, for one of six residents reviewed (Resident R1).Findings include: Review of a current facility policy entitled Verbal Orders indicated a verbal order will not be written that is not based on a conversation with the practitioner. Resident R1's clinical record revealed an admission date of 9/23/25, with diagnoses including respiratory failure, pneumonia (viral or bacterial infection of the lung), difficulty swallowing, artificial right knee, and altered mental status. The clinical record also revealed a verbal physician's order dated 10/30/25, and signed by the physician on 10/31/25, for staff member present with resident during meals. Small bites & small sips. Review of Resident R1's hospital discharge orders dated 10/30/25, lacked evidence of orders to include for staff member present with resident during meals, small bites and sips. Review of Resident R1's clinical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-26 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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, job descriptions, resident council minutes and grievances, and resident, family, and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for eight of eight residents interviewed (Residents R9, R32, R35, R37, R48, R49, R60, and R63). Findings include: Review of facility policy entitled, Answering the Call Light dated 1/20/25, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure - 1 Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name (e.g., This is Mrs. [NAME]. Mr. [NAME], how may I help you?). If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request requires another staff member, notify the individual.…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Ecited before2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety, failed to label food brought into the facility with the resident's name and use by date, and failed to maintain sanitary conditions in one of two resident refrigerators (Building 1). Findings include: Review of facility policy entitled Foods Brought by Family / Visitors, dated 1/20/25, revealed that Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item, and the use by date, Nursing staff will discard perishable foods on or before the use by date, The nursing and/or food service staff will discard 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 on 6/26/25, at 10:15 a.m. of resident freezer in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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

    Based on review of facility policy and clinical records, observations, and interviews with residents, family members, and staff, it was determined that the facility failed to maintain a sanitary, orderly, and comfortable interior/homelike environment for two of 22 residents observed (Residents R9 and R32). Findings include: A facility policy entitled, Homelike Environment dated 1/20/25, revealed Residents are to be provided with a safe, clean, and comfortable environment and encouraged to use their personal belongings to the extent as possible. Resident R9's clinical record revealed an admission date of 11/04/24, with diagnoses that included fracture of left femur (large bone above the knee), post cholecystectomy syndrome (abdominal symptoms that persist after having the gallbladder removed), high blood pressure, and atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow). Resident R32's clinical record revealed an admission date of 4/20/25, with diagnoses that included cerebral infarction (when blood flow is interrupted and blocked in the brain…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0628 — isolated
    Provide 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for two of three residents reviewed with facility-initiated transfers (Resident R12 and Closed Record Resident CR75). Findings include: A facility policy entitled Transfer or Discharge, Emergency dated 1/20/25, revealed should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures.Prepare a transfer form to send with the resident. Resident R12's clinical record revealed an admission date of 6/23/21, with diagnoses that included high blood pressure, diabetes (a health condition caused by the body's inability to produce enough insulin), and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R12 was transferred to the hospital on 2/6/25. Resident CR75's clinical record revealed an admission date of 3/19/25, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and Quality Assurance meeting attendance records, and staff interviews, it was determined that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all required committee members for two of four quarters (October 2024 and January 2025). Findings include: Review of facility policy entitled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership dated 1/20/25, indicated the quality assurance and performance program is overseen and implemented by the QAPI committee, which reports its findings, actions, and results to the administrator and governing body. The following individuals serve on the committee: Administrator, or a designee who is in a leadership role, Director of Nursing Services, Medical Director, Infection Oreventionist (nurse certified in Infection Control and Prevention), and Representatives of the following departments, as requested by the administrator: Pharmacy, Social Services, Activity Services, Human Resources, and Medical Records. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of 22 residents observed. (Resident R44) Findings include: Review of the facility policy entitled, Call system, Residents with a policy review date of 1/20/25 , revealed that residents are provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Observation of building two during medication pass on 6/23/25, at approximately 5:30 p.m. revealed Resident R44 was sitting in a bedside chair with no call bell to alert staff for assistance if necessary. Upon checking the room for the call bell cord, it was observed that there was no call bell plugged into the wall for Resident R44's bed and no call bell observed in the room. During an interview with Licensed Practical…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and elopement prevention and safe smoking interventions were effectively implemented in the facility. Findings include: The job description for the NHA revealed that the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The job description for the DON specified to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records and facility documents, and staff interviews, it was determined that the facility failed to follow physician's orders for medication administration for two of six residents reviewed (Residents R1 and R2). Findings include: Resident R1's clinical record revealed an admission date of 3/27/25, with diagnoses that included broken right lower leg, stroke, dementia, and muscle wasting. A departmental progress note dated 4/07/25, revealed that Resident R1 was transported to the hospital for evaluation and treatment of rectal bleeding. Upon return to the facility a physician's order dated 4/07/25, identified to administer Azithromycin (antibiotic) 250 milligrams by mouth daily for four days for treatment of Respiratory Syncytial Virus (RSV- seasonal, highly contagious respiratory virus that often feels like a common cold). Review of Resident R1's April 2025 Medication Administration Record (MAR) revealed that he/she did not start receiving the ordered antibiotic until 4/10/25, (three days late). Resident R2's clinical record revealed an admission date of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-24 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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, facility documentation, and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for seven of 44 residents reviewed (Residents R1, R2, R3, R4, R5, R6, and R7). Findings include: A facility policy entitled, Activities of Daily Living (ADL), Supporting dated 4/24/24, revealed Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records and resident, resident representative, and staff interviews, it was determined that the facility failed to assess and notify the resident's physician timely of a change in condition for one of four residents reviewed (Resident R1). Findings include: The facility policy entitled Acute Condition Changes - Clinical Protocol dated 4/24/24, revealed Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician, for example, the history of present illness and previous and recent test results for comparison. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). The attending…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-03 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, clinical records, facility documentation, and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 10 of 21 residents reviewed (Residents R14, R20, R61, R9, R19, R29, R36, R43, R57 and R177). Findings include: Review of a facility policy entitled Activities of Daily Living (ADL), Supporting with a revision date of March 2018, and a policy review date of 4/24/24, revealed Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (Transfer and ambulation, including walking),…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-03 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, manufacturer's instructions, observations and staff interview, it was determined that the facility failed to label one multi-dose vial of Tubersol tuberculin purified protein derivative (PPD-testing solution for tuberculosis) injection, and three pens of insulin with the date it was opened in one of two medication storage rooms and two of two medication carts observed (Building One medication storage and medication cart one Building One and [NAME] Cart Building Two). Findings include: Review of manufacturer's instructions for Tubersol-tuberculin PPD Vials revealed A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date. Review of manufacturer's instructions for Lantus insulin glargine injection pens revealed in use opened 3 ml (milliliter) single-patient-use SoloStar prefilled pen 28 days room temperature only (Do not refrigerate). Review of facility policy entitled Storage of Medications, with a policy review date of 4/24/2024, revealed that The facility stores all drugs 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-03 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policy, observations, and staff interview, it was determined that the facility did not ensure the garbage and refuse was disposed of properly. Findings include: Review of facility policy, Disposal of Garbage and Refuse, dated 4/24/24, revealed The facility shall properly dispose of kitchen garbage and refuse. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. Observations on 6/30/24, at 9:45 a.m. revealed three outside dumpsters with lids open and damaged. Garbage was observed hanging over dumpster and on ground. Further observations on 7/01/24, at 1:30 p.m. revealed dumpster lids open and damaged allowing dumpster not to be covered. Garbage was observed on ground. An interview with the Dietary Manager on 7/01/24, at 1:30 p.m. confirmed that the dumpster lids should always be closed,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-03 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a baseline care plan was developed and that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for two of 21 residents (Residents R62 and R126). Findings include: A facility policy entitled Care Plans-Baseline dated 4/24/24, indicated a baseline plan of care to meet the resident's immediate health and safety need is developed for each resident within 48 hours of admission, and the resident and/or representative are provided a written summary of the baseline care plan in a language that the resident and/or representative can understand. Resident R62's clinical record revealed an admission date of 12/06/23, with diagnoses including muscle wasting, high blood pressure, Type 2 Diabetes (impaired ability for the body to regulate and use sugar as a fuel), pancytopenia (overall decrease in all types of blood cells), and heart disease. Resident R62's clinical record lacked evidence that a baseline…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, and resident representative and staff interviews, it was determined that the facility failed to follow professional standards of care by a lack of timely physician notification for one of 21 residents reviewed (Resident R41). Findings include: Review of facility policy, Radiology, dated 4/24/24, stated The facility will ensure all x-ray/diagnostic testing will to done and reported to the medical provider in a timely manner. All positive x-ray/diagnostic results will have immediate MD/NP notification. Resident R41's clinical record revealed an admission date of 2/23/20, with diagnoses of anxiety, depression, muscle wasting and atrophy (a decrease in size of muscle tissue and mass), and pneumonia. Review of Resident R41's physician orders dated 6/25/24, revealed an order to obtain a follow-up chest x-ray (PA and Lateral) (a diagnostic study of images of the inside of your body). Clinical records for Resident R41 dated 6/25/24, revealed a chest x-ray for follow-up of pneumonia and dyspnea with findings of Only limited improvement…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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

    Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (a tubing inserted into the bladder to drain urine into a bag) care for one of 21 residents reviewed (Resident R14). Findings include: Review of facility policy, Catheter Care, Urinary, dated 4/24/24, revealed Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2. Unless specifically ordered, do not apply a clamp to the catheter. 3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses of depression, BPH (benign prostatic hyperplasia is an enlarged prostate and cause problems with urination in a man), CKD (chronic kidney disease is a longstanding disease of the kidneys), and need for a suprapubic catheter (a surgically created connection…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records and facility documentation, and staff interviews, it was determined that the facility failed to fully investigate an incident with injury for one of one residents reviewed (Resident R1). Findings include: Review of a facility policy entitled, Abuse Neglect Exploitation General Policy dated 5/12/23, revealed incidents in which a resident has been injured . should be promptly investigated. The policy indicated a list should be compiled of all witnesses and other persons who have knowledge of the event. Persons considered when interviewing/investigating would include person making the report, individuals alleged to have been involved in the incident, the resident if able and willing to be interviewed, staff on duty working on the unit during the time of the alleged incident, staff on duty working on another unit during the time on the incident that may have information about the incident, staff that may have contact with the resident before or after the period of the alleged incident, residents roommate, family members, visitors,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$19,888 in federal fines across 2 penalties.

  • $11,737 — penalty dated 2025-04-29
  • $8,151 — penalty dated 2024-02-29

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

Part of a chain

This home belongs to WECARE CENTERS — 13 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 →

RatingThis homeChain avg
Overall 2 of 51.9+0.1 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 3 of 51.9+1.1 vs chain
Quality measures 3 of 53.6-0.6 vs chain
The other 12 homes this chain runs (chain average 1.9★, 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

Investor-owned

CMS ownership filings flag an owner of this facility as a private-equity firm. That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.

  • EMSIR LLC — private equity · 10.00% share · 5% Or Greater Indirect Ownership Interest
  • KJA UPMC4 LLC — private equity · 40.00% share · 5% Or Greater Indirect Ownership Interest

Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →

Owner / managerTypeRoleShareSince
AVA HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2024
KJA UPMC4 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2024
GRINSPAN, ARYEHIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 05/01/2024
KORN, ELIIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2024
WIELGUS, GEDALIAHIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 05/01/2024
COLEMAN, SILVIAIndividualCONTRACTED MANAGING EMPLOYEEsince 05/01/2024
MAGDA, JERZYIndividualCONTRACTED MANAGING EMPLOYEEsince 05/01/2024
LEHMAN, EPIPHANYIndividualW-2 MANAGING EMPLOYEEsince 05/01/2024

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$7.7M
Net patient revenuemost recent cost report
-45.9%
Operating marginrevenue minus expenses
$1.4M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 62%Medicare 7%Other / private 32%

This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 2024. 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

$503per resident / day
operating cost
$15,291per month
≈ monthly operating cost
$345per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.

Typical monthly cost in Pennsylvania
$11,954/mo
Nursing home (semi-private)
$13,688/mo
Nursing home (private)
$6,480/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 396075. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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