No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Nottingham Village

58 Neitz Road, Northumberland, PA 17857 · For profit - Corporation · 121 certified beds · (570) 473-8366 Medicare & Medicaid certified

Call the home — (570) 473-8366 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 20241 actual-harm citation$8,018 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,018 in federal fines (most recent 2024-01-05)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1151 N Fourth St · (570) 556-4900 · Call to confirm hours
Pharmacy
401 Duke St · (570) 473-3221 · Call to confirm hours
Grocery
281 Point Township Dr · (570) 473-7102 · Call to confirm hours
Park
Bridge Ave · (570) 988-5557 · Typically dawn to dusk

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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.3%16.8%15.4%worse
Long-stay residents who lose too much weight5.4%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms1.3%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 injury2.0%3.1%3.3%better
Long-stay residents whose ability to walk worsened23.5%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.0%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine97.9%93.5%95.3%typical
Long-stay residents with pressure ulcers5.1%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control31.4%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.3%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.7%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine98.8%68.7%79.4%better
Short-stay residents rehospitalized after admission25.6%22.5%22.6%worse
Short-stay residents with an outpatient ER visit10.9%9.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.091.621.67worse
Long-stay outpatient ER visits per 1,000 resident days0.551.181.80better

§ 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.

50.8% 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 309 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.8%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
52.2%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 52.2% 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 134 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF50.8%CMS range 44.2–56.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 9.1–14.210.7%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 discharge52.2%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 discharge51.5%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 discharge41.8%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 identified92.7%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.9%98.7%Oct 2024–Sep 2025CMS 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 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 worsened4.9%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 4.3–9.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 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

0.57
RN hours/ resident / day
1.15
LPN hours/ resident / day
2.32
Aide hours/ resident / day
4.04
Total nurse hours/ resident / day
0.28
RN hoursweekends
28.6%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 121 beds and averages 109.1 residents a day — about 90% occupied, or roughly 12 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 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.64 hrs/resident/day on weekends vs 4.20 on weekdays — 13% thinner on weekends. RN hours go from 0.68 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 29% is below the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-11-14)
15
at the previous standard inspection (2024-12-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2024-01-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, facility documentation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from neglect, which resulted in actual harm with serious injuries, including diagnoses of traumatic subarachnoid hemorrhage (bleeding in the brain), right hip contusion, and scalp laceration for one of one resident reviewed for abuse (Resident 41). Findings include: The facility policy entitled Abuse Prohibition, last reviewed without changes on July 20, 2023, revealed it is the policy of the facility that every resident will be free from mistreatment, neglect, and misappropriation of property. The facility will do all that is within its control to prevent occurrences of abuse. This will be managed through a system of employee screening, staff training, resident and family awareness programs, procedures to identify abuse and contributing factors, procedures to report and investigate occurrences,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-11-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined that the facility failed to maintain food service equipment in accordance with professional standards for food service safety and store food in a sanitary manner in the facility's main kitchen and on two of three nursing units (Station 2 and Station 3). Findings include:An observation of the facility's main kitchen on November 12, 2025, at 9:30 AM with Employee 1, dietary manager, revealed the following: Debris and multiple dried brown liquid spots on the flooring underneath the coffee station area. The wall beside the area was covered in dried liquid splatter, with the broken pieces of drywall on the corner of the wall. A metal utensil rack hanging from the ceiling over the top of a food preparation table had multiple cooking utensils stored hanging from the rack such as spoon, ladles, whisks, and pans uncovered with food contact surfaces exposed to the potential for airborne particles such as dust and potential contamination and food preparation splatter from the table below it. A metal sheet tray located on a shelf under…

    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 · E2025-11-14 · tag F0699 — pattern
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to implement an individualized plan of care related to a resident's history of trauma to eliminate or mitigate re-traumatization for two of two residents reviewed for behavior and emotional status (Residents 95 and 101). Findings include:Clinical record review for Resident 95 revealed a revealed a Social History Assessment dated November 11, 2025, for the resident who was admitted on [DATE]. The assessment indicated the resident had a traumatic life event involving the death of his son who was murdered. A review of Resident 95's plan of care revealed a focus area for the resident's trauma indicating the Resident has encountered a trauma that has resulted in physical, social, or emotional harm or life-threatening situation. This trauma has continued to have adverse effects on the residents individual functioning and mental, physical, social, emotional and spiritual well-being: he reports his son was murdered. The plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide resident bathing per preference for one of 32 residents reviewed (Resident 101). Findings include: In an interview with Resident 101 on November 12, 2025, at 11:48 AM the resident stated she is supposed to be getting a shower on Tuesdays and Fridays but does not get them. Resident 101 stated it happened again the day prior on Tuesday, November 11, 2025. Resident 101 stated staff come in early and just wash her up a little in bed and get her dressed but don't take her to the shower. Resident 101 stated her family member had discussed this with facility staff prior, but she still does not get them. Resident 101 stated I was one time a week showers during the day, then it changed to the night, then we got it changed to twice a week like I like it, and I still only get one a week.Clinical record review of Resident 101's bathing task revealed Resident 101 was scheduled upon admission October 14, 2025, to receive a shower on Tuesdays during the day shift.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 23 residents reviewed (Resident 45).Findings include: Clinical record review for Resident 45 revealed a PASRR (Preadmission Screening and Resident Review, assessment required to ensure individuals are not inappropriately placed in nursing facilities and/or receive necessary services in those settings) dated November 2, 2023, that assessed her as having met the criteria for further mental health review by the Department of Human Services (DHS). A letter from DHS dated November 7, 2023, confirmed that Resident 45 met the criteria to require that she receive ongoing mental health services for a serious mental illness that would be arranged by the facility (PASRR II). An annual MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 24, 2025, incorrectly assessed that Resident 45 was not considered by the state level II PASRR process to have…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-14 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to appropriately assess the use of enabler bars for one of seven residents reviewed for accident hazards (Resident 10).Findings include: The facility policy titled, Bed Safety, last reviewed without changes on July 18, 2025, revealed the facility will try to prevent deaths and injuries from the beds and related equipment including the frame, mattress, side rails, headboard, footboard, and bed accessories. Approaches to this included, in part, inspection by maintenance staff of all beds and related equipment as part of the regular bed safety program to identify risks and problems including potential entrapment risks; and review the gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA). The policy provided by the facility did not further define the gaps. Clinical record review for Resident 10 revealed a diagnosis list that included multiple sclerosis (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility policies and procedures, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 66 and 112).Findings include: The facility's medication error rate was five percent based on 34 medication opportunities with two medication errors. The policy entitled, Administration Procedures for All Medications, last reviewed without changes on July 18, 2025, revealed procedural steps that included to check the MAR (Medication Administration Record, an electronic system used by licensed staff to document the administration of medications) for the physician's order and if unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. Observation of a medication administration pass on November 13, 2025, at 8:55 AM revealed Employee 2 (licensed practical nurse) administered Omeprazole (medication that reduces acid in the stomach and relieves symptoms such as heartburn) 40 mg…

    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 · Dcited before2025-11-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure an eligible resident received a pneumococcal vaccine for one of five residents reviewed for immunization concerns (Resident 45). Findings include: The facility policy entitled, Pneumococcal Vaccine, last reviewed without changes on July 18, 2025, revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Current CDC recommendations for the pneumococcal vaccinations note that the United States uses two types 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, review of select facility policies, and resident and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of three residents reviewed (Resident 1). Findings include: Review of the current facility policy entitled Pain Assessment/Management, revealed at the time of a pain interview, if it is determined that the resident is having pain on a scale of 7 to10, or severe pain (regardless of frequency), or is having frequent or constant pain (that the resident does not feel is tolerable), the resident will be placed on a pain management program, unless otherwise documented on the pain assessment. The pain management program consists of assessing/observing for pain at least every shift and updating the physician if pain is not being managed effectively. Pain management will be documented on the Medication Administration Record (MAR, a form utilized to document the administration of medications) by licensed staff. The charge nurse will update…

    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 before2024-12-06 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, and staff interview, it was determined that the facility failed to obtain consent for, assess the need for, and assess entrapment risks from bed assistive bars for two of two residents reviewed for accident hazards (Residents 19 and 108). Findings include: Observation of Resident 19 on December 4, 2024, at 11:52 AM revealed she was in bed with assist bars mounted bilaterally at the head of her bed. Resident 19's bed was also equipped with a headboard and a footboard. The surveyor requested evidence of an assessment for need, an assessment for entrapment risks, and consent for the use of the bed assistive devices for Resident 19 during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 8 (registered nurse/infection control prevention coordinator) on December 4, 2024, at 2:00 PM. Interview with the Nursing Home Administrator on December 5, 2024, at 10:10 AM indicated that the facility utilized a bed system measurement device to assess four zones of potential entrapment risks presented with the use of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-06 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure routine prophylactic dental services for one of three residents reviewed for dental concerns (Resident 62). Findings include: Interview with Resident 62 on December 3, 2024, at 12:49 PM revealed that he had natural teeth, but the, hygienist has never been here. Resident 62 indicated that no dental professional had cleaned his teeth, and he brushes his teeth. Interview with the Director of Nursing on December 5, 2024, at 10:40 AM confirmed that there was no evidence that a hygienist or dental professional provided prophylactic (preventative) cleaning of Resident 62's teeth in the past year. Following the interview with the Director of Nursing, the facility provided one progress note from the facility's consulting dental provider dated September 17, 2024, that was noted as an annual exam by the dentist. The progress note indicated that there was heavy soft plaque/food debris buildup, light hard calculus (hard deposit when soft plaque becomes calcified) deposits,…

    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
Show the remaining 20 citations
  • Potential for harm · Ecited before2024-12-06 · 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

    Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on December 3, 2024, between 7:55 AM and 9:00 AM revealed the following: The dry storage goods area revealed the following: A bag of elbow macaroni had a blank date sticker on it and contained no open or use by date. There was a hole in the bottom of the bag. A temperature control unit on the wall had a significant accumulation of a black substance on the vents. An open container of whole rosemary had an expired use date of May 2024. An open container of blue food coloring had an unreadable use by sticker. The bottle was hand dated 1-30-19. The walk-in freezer contained several cardboard boxes that held food items (snickerdoodle dough, whipped topping, and cherry turnovers) that were located under the internal circulation fans. The boxes had a large accumulation of ice on them. A walk-in cooler contained eight cardboard boxes 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-06 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for three of three residents reviewed with a signed arbitration agreement (Residents 19, 62, and 68). Findings include: Review of an Agreement to Resolve Disputes by Voluntary Mediation and/or Mandatory Binding Arbitration, (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving the right to a trial) signed by Resident 19 on February 22, 2023, revealed that the document stipulated that, Subject to Section 6 of this Agreement, the Arbitration shall be administered by (name of arbitrator services company designated by the facility). In the event (name of arbitrator services company designated by the facility) is unable or unwilling to serve, then the request for Arbitration must be submitted to the Facility within thirty (30) days of receipt of notice 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for one of 23 residents reviewed (Resident 108). Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting the right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. Observation of Resident 108 on December 3, 2024, at 11:26 AM and 1:14 PM revealed Resident 108 was in bed with her call bell attached to the top of the assist bar rail at the head of her bed. Resident 108 was unable to reach her call bell. Observation of Resident 108 on December 4, 2024, at 11:17 AM 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of an investigation of an unknown injury for one of one resident reviewed (Resident 28). Findings include: The policy entitled Abuse Prohibition last reviewed on July 18, 2024, indicates that the facility uses an incident reporting system to report, investigate, and track all unusual incidents. Incidents of unknown origin are investigated according to the facility's stand-up meeting/investigation of unusual incidents. Suspicious injuries, occurrences, trends, or patterns that may constitute abuse are identified and investigated. Review of Resident 28's clinical record revealed nursing documentation dated September 26, 2024, at 2:30 PM that indicated Resident 28 was complaining of right leg pain. Nursing staff administered Tylenol (for pain relief) that was ineffective and notified Resident 28's physician. Nursing documentation dated September 27, 2024, at 2:30 PM indicated that Resident 28…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 23 residents reviewed (Residents 108 and 112). Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting her right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. Further review of Resident 108's clinical record revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 25, 2024, in which facility staff assessed Resident 108 as…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · 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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure quality of care related to a cardiac pacemaker use for one of 23 residents reviewed (Resident 68). Findings include: Interview with Resident 68 on December 4, 2024, at 11:14 AM revealed that she had a history of heart disease, and that she had a cardiac pacemaker (medical device implanted in the chest with wires to the heart to deliver electrical signals to control a heart rate) placed. Resident 68 pointed to an electronic device on her bedside stand and stated that a representative from the pacemaker monitoring company calls the nurses' station when she begins to show signs that fluid is accumulating in her body. Resident 68 stated that her Lasix (diuretic medication, used to remove excess fluid from the body) is sometimes adjusted because of this symptom change. Clinical record review for Resident 68 revealed no physician orders or plan of care that indicated that Resident 68 had a cardiac pacemaker. Diagnoses listed in Resident 68'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to implement a restorative nursing program as recommended by therapy to ensure a resident with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion for one of three residents reviewed (Residents 108). Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following a cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. She stated that she no longer receives physical therapy. Review of Resident 108's admission Minimum Data Set (MDS, an assessment completed at specific…

    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 · D2024-12-06 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement care to prevent potential complications from a dialysis access site for one of one resident reviewed for dialysis services (Resident 62). Findings include: Interview with Resident 62 on December 3, 2024, at 12:58 PM revealed that he required dialysis treatments (treatment for kidney failure; a machine filters extra fluid and waste products from the blood) three times a week, and that the treatment was administered through a fistula (surgical connection between an artery and a vein making a larger blood vessel for dialysis treatment) located in the area over his right bicep (upper arm) muscle. Resident 62 stated that staff obtain blood pressure assessments from his leg. Resident 62 stated, Once in a while a nurse will come in and think that she's going to take it in my arm, but I tell her to do it in my leg. Observation of Resident 62 and his room during the interview revealed no indicators that Resident 62 had right arm use restrictions. 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 · D2024-12-06 · tag F0725 — failed to have enough nursing staff — isolated
    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 observations, clinical record review, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs related to call bell response time for two of 23 residents reviewed (Resident 19 and 52). Findings include: Interview with Resident 19 on December 4, 2024, at 11:34 AM revealed that when she rings her call bell, staff will come in and then say they will be back but never come back. Review of Resident 52's Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated November 11, 2024, indicated the facility assessed her as being cognitively intact and needing the extensive assistance of two staff members for toileting. Observation on December 3, 2024, at 9:54 AM revealed that Resident 52 rang her call bell. The call bell continued to ring until 10:26 AM, 32 minutes after Resident 52 initiated the call bell. At 10:26 AM, Employee 1, nurse aide, entered Resident 52's room, the call light went out, and Employee 1 immediately walked back out of Resident…

    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 · D2024-12-06 · tag F0761 — failed to label and store drugs safely — isolated
    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 observation and staff interview, it was determined that the facility failed to ensure adequate labeling and storage of medications and biologicals on one of three nursing units (Station III) and for one of 23 residents reviewed (Resident 29). Findings include: Observation of the Station III nursing unit on [DATE], at 10:41 AM revealed an unlocked medication cart. The medication cart was sitting in a heavily occupied area of the nursing station. The unlocked medication cart was accessible to non-licensed staff, visitors, and other residents. The unlocked medication cart remained unattended until 10:46 AM. Interview with Employee 3, licensed practical nurse, on [DATE], at 10:46 AM confirmed the above observations. During a medication administration observation on [DATE], at 9:00 AM revealed Employee 2, licensed practical nurse, administering medications to Resident 29. Employee 2 indicated that Resident 29 administers her own eye drops. Employee 2 prompted Resident 29 to find her eye drops and administer…

    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 · Dcited before2024-12-06 · 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 a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement transmission-based precautions for one of 23 residents reviewed (Resident 103). Findings include: Review of the facility policy, Contact Precautions, last reviewed without changes on July 18, 2024, revealed that in addition to standard precautions, use contact precautions for specified residents known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin-to-skin contact that occurs when performing resident care activities that require touching the resident's dry skin) or by indirect contact (touching) with environmental surfaces or resident care items in the patient's environment. In addition to wearing a gown as outlined under standard precautions, wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer and administer an influenza immunization unless refused for one of five residents reviewed for immunizations (Resident 3). Findings include: The facility policy entitled, Influenza Vaccine, last reviewed without changes on July 18, 2024, revealed that residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1st and October 31st each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident has already been immunized. Prior to vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical record. For those who receive 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer and administer a COVID immunization for one of five residents reviewed for immunizations (Resident 3). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed without changes on July 18, 2024, revealed that each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. The resident (or resident representative) could accept or refuse a COVID-19 vaccine, and to change his/her decision. COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident/resident representative is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Residents/resident representatives must sign a consent to vaccinate form…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure the proper safety and security of medication dispensing for one of three residents reviewed (Resident CR1). Findings include: The policy entitled Storage of Medications, last reviewed on January 20, 2024, indicates that the medication supply is accessible only to licensed nursing personnel or staff members lawfully authorized to administer medications. The policy entitled Administration Procedures for all Medications, last reviewed on January 20, 2024, does not include written guidance ensuring that the licensed nurse who pours the medication should also be the same person who administers the medication. Review of Resident CR1's closed clinical record revealed that the facility admitted her on January 8, 2024, for end-of-life care. A physician's order dated January 11. 2024, indicated that nursing staff were to administer Morphine (a narcotic pain reliever) 20 mg (milligrams) per ml (milliliters) .25 ml (milliliters) every one…

    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 · D2024-01-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure accurate and complete clinical documentation for one of 3 residents reviewed (Resident CR1). Findings include: Review of Resident CR1's closed clinical record revealed that the facility admitted her on January 8, 2024. A physician's order dated January 11. 2024, indicated that nursing staff were to administer Morphine (a narcotic pain reliever) 20 mg (milligrams) per ml (milliliters) .25 ml (milliliters) every one hour as needed for terminal distress. Interview on January 25, 2024, at 10:15 AM with Employee 1, licensed practical nurse, revealed that on the weekend of January 13, 2024, or January 14, 2024, she prepared a dose of Resident CR1's morphine and handed the syringe to Employee 2, licensed practical nurse, to administer. Employee 2 was visiting Resident CR1 but on medical leave from the facility when Employee 1 let her administer the morphine to Resident CR1. Employee 1 indicated that she signed off Resident CR1's morphine administration as if she gave it on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-05 · 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

    Based on observation and staff interview, it was determined that the facility failed to store food and maintain equipment in a sanitary manner and ensure temperature monitoring was in place to prevent the potential spread of food borne illness in the facility's main kitchen. Findings included: An observation of the facility's main kitchen with Employee 1 (food service director) on January 2, 2024, from 9:39 to 9:56 AM revealed the following: In the dry storage room, there was a bag of frosted flakes cereal opened, not secured, and not dated. There was a bag of powdered sugar opened with a use-by date of December 21, 2023, available for use. In the freezer, there was an open bag of frozen chicken breasts, with three chicken breasts, not secured, or dated. In the refrigerator, there was a pan of prime rib, covered with no date. An interview with Employee 1 revealed that the meat was cooked prior. Observation of the cool-down logs with Employee 1 on January 2, 2024, at 9:46 AM revealed the prime rib was listed on the log but there were no temperatures recorded. An interview with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-05 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information and a resident's right to privacy for one of three nursing units reviewed (Nursing Unit 1; Residents 9, 37, and 57). Findings include: Observations on January 2, 2023, at 11:09 AM and January 3, 2023, at 9:06 AM revealed two treatment carts located in the hallway of Nursing Unit 1. On the top of each cart was a binder that had a typed document attached to the outside of the binder that was clearly visible to anyone passing by the cart. The attached document contained information for several residents in the facility that included diagnosis information and instances of protected health information for each resident listed on the sheet. Resident 9's name was clearly visible with a notation that the resident had a colostomy. An interview with Employee 4, licensed practical nurse, on January 3, 2023, at 9:06 AM revealed that the document and associated binder were related to keeping track of supplies that were used during various treatments.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 2). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 2 revealed a current physician's order for staff to administer Oxygen 2 LPM (liters per minute) via nasal cannula (NC, tubing to deliver Oxygen via the nose) at HS (hour of sleep, bedtime). Observation of Resident 2's Oxygen concentrator on January 2, 2024, at 11:18 AM revealed that their Oxygen was set at 3 LPM. Concurrent interview with Resident 2 revealed that the Oxygen concentrator…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-05 · 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 observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection regarding transmission-based precautions on one of three nursing units (Nursing Unit 1; Resident 44). Findings include: Review of the policy titled, Droplet Precautions, last reviewed without changes on July 20, 2023, revealed that in addition to standard precautions, droplet precautions will be used for residents with known or suspected to have serious illnesses transmitted by droplets (large particle droplets) that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures. An illness list included COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus). The policy further noted to wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities when there is an expectation of possible exposure to infectious material. Review…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-01-05 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for one of four residents reviewed (Resident 8). Findings include: A review of Resident 8's clinical record revealed that the facility transferred her to the hospital on November 5, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 8's transfer to the hospital. Interview with Employee 2, social worker, on January 4, 2024, at 10:14 AM confirmed the above findings and indicated that she had not sent any transfer notices to the Office of the State Long-Term Care Ombudsman for resident transfers. Employee 3 indicated that she was pulling the wrong report and transfers were not listed on the report that she sent. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

    Resident Rights 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

$8,018 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $8,018 — penalty dated 2024-01-05
  • Medicare payment denial — starting 2025-01-29 for 1 days

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

Who owns this facility

Owner / managerTypeRoleShareSince
RIDGWAY HOLDING, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/04/2003
FREDERICK KESSLER JR ESTATEOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 11/09/2018
SCOTT, ROBERTIndividualCONTRACTED MANAGING EMPLOYEE; ADP OF THE SNFsince 01/07/2025
GESUMARIA, BETHIndividualW-2 MANAGING EMPLOYEEsince 08/30/2023
SHEBEST, STUARTIndividualW-2 MANAGING EMPLOYEE; ADP OF THE SNFsince 01/07/2025
KESSLER, AMANDAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/01/2024
MISENER, ANDREWIndividualCORPORATE OFFICERsince 05/01/2024

CMS files one row per role, so the 10 rows in the source record cover these 7 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.

$19.6M
Net patient revenuemost recent cost report
-6.6%
Operating marginrevenue minus expenses
$456K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 12%Other / private 33%

This home reported $456K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$588per resident / day
operating cost
$17,889per month
≈ monthly operating cost
$552per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

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 395390. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-14, 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.

What to do next