Quality Life Services - New Castle
520 Friendship Street, New Castle, PA 16101 · For profit - Limited Liability company · 204 certified beds · (412) 654-7791 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 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 | 11.9% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.4% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.7% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.1% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 31.3% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.8% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 97.6% | 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 | 9.0% | 9.5% | 12.0% | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.3% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.9% 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 29 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% 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 | 47.3%CMS range 35.3–58.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 8.5–17.1 | 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 | 37.9% | 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 | 44.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.9% | 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 | 95.8% | 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 | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 4.4–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 204 beds and averages 138.2 residents a day — about 68% occupied, or roughly 66 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.19 hrs/resident/day on weekends vs 3.52 on weekdays — 10% thinner on weekends. RN hours go from 0.61 to 0.28 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · E2026-05-21 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance forms, and access to the grievance box by wheelchair dependent residents to enable filing grievances anonymously in the main entrance.Findings include: Review of a facility policy entitled Communication of Resident, Family and Staff Concerns and Grievances Article VIII dated 1/13/26 indicated that the facility will encourage residents to communicate a concern or grievance verbally or by completing a Concern Form independently and/or with assistance; forms can be obtained by contacting the Administrator (NHA), Director of Nursing (DON), or Social Services Director (SSD); and forms are located at any nurse's station. Interview with Resident Council members on 5/19/26, from 11:00 a.m. to 12:00 p.m. confirmed that they do not know where the grievance box is or how to get forms to file a concern anonymously. Observation on 5/19/26, at 12:04 p.m. of the grievance box located at the front entrance of the building revealed there were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-21 · tag F0628 — patternProvide 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 policies, clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), upon or within twenty-four hours of transfer for two of eight residents reviewed for hospitalization (Residents R2 and R9) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for six of eight residents reviewed for hospitalization (Residents R2, R8, R9, R11, R118, and Closed Record CR147). Findings include: Facility policy entitled Notice of Bed-Hold Policy for a Hospitalization or Therapeutic Leave dated 1/13/26, revealed that during a hospitalization or therapeutic leave the resident will be offered the opportunity to reserve their residency. It further revealed that depending on how the residents stay is financed determines how they are affected and they are asked…
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 before2026-05-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for seven of 30 residents (Residents R7, R24, R31, R41, R75, R87, and R155).Findings include: Facility policy entitled, Oxygen Concentrator [medical device that extracts oxygen from the surrounding air, filters it, and delivers oxygen-enriched air to patients with low blood oxygen levels] dated 1/13/26, indicated to change the water bottle weekly, or more if needed; clean the outside of the concentrator with disinfectant when it becomes soiled; after a concentrator is discontinued, place the equipment in the soiled utility room. Facility policy entitled, Oxygen Therapy via Nasal Cannula-NU14.7 dated 1/13/26, indicated that the nasal cannula [NC- thin, lightweight, and flexible tube that splits into two small prongs inserted into the nostrils, allowing oxygen or a mixture of air and oxygen to flow directly into the respiratory system] will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-21 · 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
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 discard of and properly label after opening multi-dose insulin (medication to treat elevated blood sugar levels) pens with the date it was opened, and failed to discard of one multi dose insulin pen and one [NAME] dose vial of Tubersol (an injectable diagnostic solution test to determine if a person has been infected with tuberculosis) in two of four medication carts (2 west cart 2, east 2 cart 2) and one of two medication storage rooms reviewed (East Med storage room). Findings include: A facility policy entitled Medication storage in the facility last reviewed 1/13/26, revealed drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is in a multi-dose injectable vial or an item for which the manufacturer has specified a usable life after…
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 · D2026-05-21 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Food Committee and Resident Council minutes, and resident and staff interviews, it was determined that the facility failed to respond to resident concerns identified during Resident Council and Food Committee minutes for three months reviewed (February 2026, March 2026, and April 2026).Findings include: Review of the 2/24/26, Food Committee meeting minutes revealed residents reported they are not receiving their snacks in the evening and requested that the snack cart be left by the nurse's station. There was no evidence that concerns and/or resolutions of concerns from the previous meeting were discussed.Review of the 3/03/26, Food Committee meeting minutes revealed residents reported they are not receiving snacks, staff are not in the dining room to pass trays, they would like condiment packets (hot sauce, honey mustard, ranch) and they would like less fish on the menu. There was no evidence that concerns and/or resolutions of concerns from the previous meeting were discussed.Review of the 4/28/26, Food Committee meeting minutes revealed residents reported they…
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 · D2026-05-21 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of an as needed (PRN) psychotropic (mind altering) medication beyond 14 days for one of five residents reviewed for unnecessary medications (Resident R6).Findings include: Resident R6's clinical record revealed an admission date of 10/14/25, with diagnoses including Type 2 Diabetes [happens when the body cannot use insulin correctly and sugar builds up in the blood], Charcot's Joint-ankle and foot [degenerative joint disorder characterized by the progressive destruction of the joint], heart failure, and chronic obstructive pulmonary disease [COPD- common lung disease causing restricted airflow and breathing problems]. Resident R6's clinical record revealed a physician's order to administer hydroxyzine (anti-anxiety medication) 25 milligrams (mg) by mouth every eight hours as needed dated 10/14/25 and discontinued on 3/17/26. Review of Resident R6's Medication Administration Record (MAR) revealed he/she received…
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 · D2026-05-21 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 30 residents reviewed (Resident R5) and failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for one of 30 residents reviewed (Resident R136). Findings include: Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 30 residents reviewed (Resident R5) and failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for one of 30 residents reviewed (Resident R136). Findings include: Facility policy dated 1/13/26, entitled Comprehensive Care Plan revealed…
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 · D2026-05-21 · 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
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 23 residents reviewed (Resident R7).Findings include: Review of the Nursing Facility Hospice Services Agreement dated 8/29/19, indicated that the 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 are to be legible, clear, complete; and each such record shall be readily available on request by an authorized federal, state, of local government or regulatory agency. Resident R7's clinical record revealed an admission date of 1/25/24, with diagnoses including encounter for palliative care [specialized medical care focused on improving quality of life and relieving symptoms for people with serious illnesses], dementia, kidney disease, heart failure, and Type 2 Diabetes [happens when the body cannot use insulin correctly and sugar builds up in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-21 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 policies, observations, and staff interview, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line and ensure that food was stored in accordance with standards for food safety in two of three resident pantries checked (1 [NAME] and East Wing pantries).Findings include: Review of a facility policy entitled Food Safety and Sanitation dated 1/13/26, revealed All local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department; Hair restraints are required and should cover all hair on the head; beard nets are required when beard is longer than .5 inches or untrimmed; Food with expiration dates are used prior to the use by date on the package. Review of a facility policy entitled Food Brought in From Outside Sources dated 1/13/26, revealed Food brought in from family and visitors will be stored in the refrigerators located on each unit; Items brought into the facility must be labeled with the resident name and the date it was prepared ;Condiment-type…
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 before2026-05-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during a dressing change for one of two residents with pressure ulcers requiring wound care reviewed (Resident R5). Findings include: Facility policy entitled Enhanced Barrier Precautions dated 1/13/26, revealed EBP are utilized to prevent the spread of multi-drug organisms to residents. Policy further revealed that gloves and gowns are applied prior to performing the high contact resident care activities, which includes wound care. Resident R5's clinical record revealed an admission date of 1/13/24, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), End Stage renal Disease (ESRD - when the kidneys have permanently lost their ability to function effectively. A person typically requires regular dialysis or a kidney transplant to survive), and High Blood Pressure. Resident R5's clinical record…
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 16 citations
- Potential for harm · D2025-12-02 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 interviews, it was determined that the facility failed to ensure that in preparation for a room change, the resident and/or resident's responsible party received written notice, including the reason for the change, before the resident's room was changed for five of seven residents reviewed with a room change (Residents R1, R2, R3, R4, and R5). Findings include: Review of facility policy entitled Transfer within the care community dated 1/8/25, indicated The Social Worker will contact family members/responsible parties to discuss room changes. Review of Resident R1's clinical record revealed an admission date of 1/7/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R1's documentation revealed a progress noted dated 8/26/25, that he/she was moved to a different room in the facility. Resident R1's clinical record lacked evidence that he/she was asked if they would agree to a room…
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 · E2025-05-08 · tag F0655 — patternCreate 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 the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual October 2024 (RAI-assessment guide used to plan the provision of care for residents), and clinical record review, and staff interview, it was determined that the facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to the resident and/or representative for four of 13 residents reviewed (Resident R119, R28, R129, and R383). Findings include: No policy provided by facility. Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS-a test to help determine a resident's cognitive status) revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. Resident R119 's clinical record revealed an admission date of 12/27/24, with diagnoses that included dementia (a disease of the brain that affects behavior, moods and decision making), protein-calorie malnutrition (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on a review of facility records, observations, and staff interview, it was determined the facility failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen. Findings include: Review of the manufacturer guidelines for the Manitowoc S Model Ice Machine, dated 8/25/03, revealed Do not trap drain line, leave air gap between drain tube and drain. Observations in the kitchen on 5/05/25, at 11:15 a.m., revealed the ice machine hose drain resting on a floor drain and lacked a vertical air gap between the end of the hose drain and floor drain. The floor drain and surrounding floor were observed rusty in color and unclean. An interview with the Maintenance Director on 5/05/25, at 12:15 p.m. confirmed the ice machine's hose drain and floor drain lacked an air gap, allowing the ice machine hose drain to rest on the unclean floor drain creating unsafe storage for ice. 28 Pa. Code 201.14(a) Responsibility of licensee
- Potential for harm · D2025-05-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 interview, it was determined that the facility failed to ensure the privacy and dignity of residents with an indwelling foley catheter (tubing inserted into the bladder to drain urine) for two of three residents reviewed for catheters (Residents R129 and R383). Findings include: Review of facility policy entitled Indwelling Urinary Catheter dated 1/8/25, revealed If the bed is placed in a low position, the catheter bag can be placed in a basin to prevent it from touching the floor, and The catheter bag should have a privacy cover applied at all times. Resident R129's clinical record revealed an admission date of 4/8/25, with diagnoses that included kidney failure (condition where the kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), cellulitis of right toe (bacterial infection of the skin and underlying tissues), and high blood pressure. Resident R129's clinical record revealed a physician's order dated 4/11/25, for an indwelling foley catheter.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual October 2024 (RAI-assessment guide used to plan the provision of care for residents), clinical records and facility policy, and resident and staff interviews, it was determined that the facility failed to notify the resident's representative of a change in condition and/or treatment for one of six residents reviewed (Resident R22). Findings include: Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS-a test to help determine resident cognitive status) revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. Facility policy entitled Communication of Health Status / Notification of Family dated 1/8/25, revealed that residents and/or residents' family are to be provided with information regarding the resident's total health status and that residents family and/or responsible party will be notified of a residents change 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.
- Potential for harm · D2025-05-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to ensure adequate physician orders were in place for an indwelling urinary catheter (a medical device that helps drain urine from the bladder) and failed to provide appropriate care for one of three residents reviewed for catheters (Resident R383). Findings include: Review of facility policy entitled Indwelling Urinary Catheter dated 1/8/25, revealed If the bed is placed in a low position, the catheter bag can be placed in a basin to prevent it from touching the floor, and The catheter bag should have a privacy cover applied at all times. Review of facility policy entitled Catheter: Care of Indwelling Urinary dated 1/8/25 revealed verify physician order, and secure catheter tubing to keep the drainage bag below the level of the resident's bladder and off the floor. Resident R383's clinical record revealed an admission date of 5/02/25, with diagnoses that included amputation of left foot (the surgical removal of a body part due to severe injury,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for three of three residents reviewed (Residents R1, R22, and R28). Findings include: A facility policy entitled, Oxygen Concentrator (device that takes air from your surroundings, extracts oxygen and filters it into purified oxygen to breathe) dated 1/8/25, revealed do not run concentrator without a filter or with a dusty filter, and remove, rinse and pat dry air intake filter weekly or more often if needed to keep clean and free of dust. Resident R1's clinical record revealed an admission date of 10/18/22, with diagnoses that included obstructive sleep apnea (a disorder that makes you stop breathing repeatedly during sleep), End Stage Renal Disease (ESRD-a condition in which the kidneys lose the ability to remove waste and balance fluids), and high blood pressure. Resident R1's clinical record revealed a physician's order dated 2/15/25, for oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility documents and clinical records, and resident and staff interview, it was determined that the facility failed to maintain complete and accurate records relating to dialysis (a medical procedure that filters blood when the kidneys are not functioning properly) communication for one of three residents reviewed for dialysis (Resident R28). Findings include: Review of the Long Term Care Facility Dialysis Services Agreement signed on 7/25/19, revealed that the facility agrees to provide to the Dialysis Center all medical and administrative information relating to the resident's condition. This information includes but is not limited to the resident's history of renal illness, record of laboratory and x-ray findings, and current treatment including medications. The agreement further stated that the Dialysis Center will provide to the facility appropriate information and guidance regarding the renal condition of the resident including but not limited to medications, directions for handling medical and non-medical emergencies, and care of the shunts 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 · Dcited before2025-05-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 policy, observations, and staff interview, it was determined that the facility failed to label a multi-dose insulin (medication to treat elevated blood sugar levels) vials with the date it was opened, in two of three medication carts (Cart 1 and Cart 2). Findings include: A facility policy entitled Vials and Ampules of Injectable Medications last reviewed [DATE], directed staff to place a date opened sticker on a vial or container when opened and to enter the date the container or vial was opened along with the expiration date of the medication. Observations on [DATE], from 10:45 a.m. through 10:55 a.m., revealed three opened undated multi-dose insulin vials in Medication Cart 1 and two opened undated multi-dose insulin vials in Medication Cart 2, therefore staff were not able to determine how long the vials were able to be used. The manufacturer's directions for these multi-dose insulin vials indicated that the insulin expired 28 days after opening and should be thrown away 28 days…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents reviewed related to infection control (Resident R383). Findings include: Facility policy entitled Enhanced Barrier Precautions dated 1/8/25, indicated that Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of MDRO's (Multidrug Resistant Organisms - a germ resistant to many antibiotics), and EBP's are used as an infection prevention and control intervention to reduce the spread of MDRO's to residents. The policy further stated examples of high-contact resident care activities requiring the use of EBP 's included the following: Device care or use for urinary catheters and wound care. The Center for Disease Control and Prevention (CDC) defines Enhanced Barrier Precautions as an infection control intervention designed to reduce transmission of MDRO's using an approach of isolation gown and gloves during high-contact resident care activities including catheter care and wound care. CDC…
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 before2024-10-25 · 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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly maintain kitchen equipment and maintain sanitary operations in the main kitchen. Findings include: Review of a facility policy entitled Dietary Oven and Stove Cleaning Schedule dated 6/27/24, revealed that on a daily basis the ovens and stovetops must be wiped down and staff are to wipe up spills and excess food that is left. The policy also revealed that on a monthly basis the ovens and stoves must be deep cleaned including all interior and exterior walls, oven racks, oven trays, stovetop burners, stove interior, and stove exterior. Review of a facility policy entitled Employee Sanitary Practices, dated 6/27/24, revealed that all employees shall wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Observation on 10/23/24, at 11:02 a.m. revealed two stove tops with gas burners containing a large amount of dried food and debris, the front of the three oven doors contained what appeared to be dried liquid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-25 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 closed clinical records and staff interview, it was determined that the facility failed to notify a medical provider of a need to alter treatment due to resident symptoms and/or complaints for one of seven residents reviewed (Closed Record Resident CR1). Findings include: Facility policy entitled Physician Notification dated 6/27/24, revealed that staff are to communicate change in resident's condition to the physician and initiate interventions as needed / ordered. Further review of the policy revealed that staff are to document physician notification and response. Resident CR1's clinical record revealed an admission date of 6/5/24, with diagnoses that included depression, high blood pressure, and anxiety. Review of Resident CR1's clinical record revealed nursing progress notes dated 6/25/24, at 5:52 a.m. where Resident CR1 was demanding Benadryl (medication to help address allergies and symptoms) for complaint of itch and was informed he/she currently did not have a physician's order and it was early in the morning. Another progress noted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 and manufacturer's instructions, observations and staff interview, it was determined that the facility failed to label one multi-dose vial of Aplisol-tuberculin purified protein derivative (PPD-testing solution for tuberculosis) injection with the date it was opened in one of three medication storage rooms observed (Two East Hall). Findings include: Review of manufacturer's instructions for Aplisol- tuberculin PPD Vials revealed Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of facility policy entitled Storage of Medications, last reviewed 6/27/23, revealed that Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Observations of the Two East Hall medication room on 6/14/24, at approximately 10:30 a.m. revealed that one multi-dose vial of Aplisol-Tuberculin PPD was opened and was currently in use, but not labeled with the opened date. At the time of the observation, the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-11 · 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 observations, review of facility policies, review of the Pennsylvania Department of Health 2023-PAHAN-694-05-11-UPD, Update: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings and staff interviews, it was determined that the facility failed to follow infection control measures to prevent possible cross contamination on one of two units (2-West). Findings include: Review of the Pennsylvania Department of Health 2023-PAHAN-694-05-11-UPD, Update: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings states As SARS-COV-2 transmission in the community increases, the potential for encountering asymptomatic or pre-symptomatic patients with SARS-COV-2 infection also likely increases. In these circumstances, healthcare facilities should consider implementing broader use of respirators and eye protection by Healthcare Provider (HCP) during patient care encounters as described below: .NIOSH approved particulate respirators with N-95 filters or higher can also be used by HCP working in other situations…
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 · C2026-05-21 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and staff interview, it was determined that the facility failed to ensure that the required nursing staffing information was posted on a daily basis.Findings include: Observations on 5/19/26, at 10:25 a.m. revealed that the daily staffing posting was not publicly posted in the facility. During interview at the time of the observation, the lack of the posting was confirmed by the Nursing Home Administrator. 28 Pa. Code 201.14 (a) Responsibility of Licensee
- No harm found · B2026-05-21 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, facility documentation, facility policies, and staff interview, it was determined that the facility failed to maintain complete and accurate records for six of 31 residents (Residents R3, R19, R59, R87, R114 and Closed Record CR150).Findings include: Review of facility policy entitled Admission dated 1/13/26, revealed that staff will complete an inventory of all belongings; document on the inventory form; sign and date the form; have resident/family sign. Review of facility policy entitled, Care of Resident's Belongings dated 1/13/26, revealed that an inventory of personal effects will be completed when the resident is admitted to the care community, transferred or discharged ; be completed by nursing staff with the assistance of the resident or family; and that it must be signed by two people. A facility document located in the inventory binder at the nurse's station and provided by the facility on 5/20/26, indicated that social services will check for completion the next working day after admission. Resident R3's clinical record revealed an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to QUALITY LIFE SERVICES — 10 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 | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 3 of 5 | 4.1 | -1.1 vs chain |
The other 9 homes this chain runs (chain average 2.7★, 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 |
|---|---|---|---|---|
| TACK, STEVEN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 33% | since 07/01/2024 |
| TACK-BEARDSLEY, SUSAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 33% | since 07/01/2024 |
| ALLISON, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2024 |
| MARKIVICH, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2024 |
| TACK-YUREK, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2024 |
| GOLDEN HILL NURSING AND REHAB LP | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| HOLSINGER PC | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| CARTER, CHRISTINE | Individual | ADP OF THE SNF | — | since 07/01/2024 |
| KANIA, TONIA | Individual | ADP OF THE SNF | — | since 07/01/2024 |
| MOSES, ROBERT | Individual | ADP OF THE SNF | — | since 07/01/2024 |
| STAFFORD, LISA | Individual | ADP OF THE SNF | — | since 07/01/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 11 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.
About 77% 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 $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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
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
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 395003. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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 →
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