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Oakwood Heights Village

10 Vo Tech Drive, Oil City, PA 16301 · For profit - Limited Liability company · 106 certified beds · (814) 676-8686 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseResident-funds citations (F0565, F0567)Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,015 in federal fines
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2025
  • 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 citations for mishandling residents’ money or property (F0565, F0567)
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,015 in federal fines (most recent 2025-02-26)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)
  • CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
155 E Bissell Ave · (814) 677-1180 · Call to confirm hours
Pharmacy
204 E 2nd St · (814) 677-4007 · Call to confirm hours
Grocery
220 Bishop Ave · (814) 670-0555 · Call to confirm hours
Park
Hasson Park Rd · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.6%16.8%15.4%worse
Long-stay residents who lose too much weight9.0%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.7%0.9%better
Long-stay residents with a urinary tract infection2.8%1.5%2.0%worse
Long-stay residents with depressive symptoms18.4%10.8%6.5%worse
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.1%3.1%3.3%typical
Long-stay residents whose ability to walk worsened15.6%17.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication13.9%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine83.1%93.5%95.3%worse
Long-stay residents with pressure ulcers2.0%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control34.3%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table26.5%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.2%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine20.5%68.7%79.4%worse
Short-stay residents rehospitalized after admission27.4%22.5%22.6%worse
Short-stay residents with an outpatient ER visit18.3%9.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.341.621.67worse
Long-stay outpatient ER visits per 1,000 resident days2.441.181.80worse

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.6% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.6%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
29.0%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 29.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.6%CMS range 40.0–61.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.4–14.610.7%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 discharge29.0%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 discharge32.3%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 discharge22.6%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 identified97.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.1%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 worsened0.0%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 hospitalization6.6%CMS range 3.3–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.661.02Oct 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

0.65
RN hours/ resident / day
1.05
LPN hours/ resident / day
1.86
Aide hours/ resident / day
3.56
Total nurse hours/ resident / day
0.49
RN hoursweekends
60.2%
Total nursing turnover
64.7%
RN turnover

How full it usually is: this home is certified for 106 beds and averages 84.8 residents a day — about 80% occupied, or roughly 21 beds typically open. It usually has some room. 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 3.18 hrs/resident/day on weekends vs 3.72 on weekdays — 14% thinner on weekends. RN hours go from 0.72 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.

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

14
deficiencies at the latest standard inspection (2026-02-06)
4
at the previous standard inspection (2025-02-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 13 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2025-10-22 · 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

    Based on review of facility policy, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident was free of neglect during care which resulted in actual harm of a laceration to the right forehead and an intraventricular hemorrhage (brain bleed) for one of 11 residents reviewed (Resident R1).Findings include: The Abuse, Neglect, and Exploitation policy, dated 1/14/25, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident R1's clinical record revealed an admission date of 8/18/19, with diagnoses that included Alzheimer's Disease (a progressive disorder that affects memory,…

    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
  • Actual harm · Gcited before2025-10-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to provide the required level of assistance with bed mobility (rolling side to side or turning in bed) as identified in the plan of care, task order summary, and in accordance with facility policy which resulted in actual harm of a laceration to the right forehead and an intraventricular hemorrhage (brain bleed) for one of 11 residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: The Safe Resident Handling/Transfers policy, dated 1/14/25, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident . Resident R1's clinical record revealed an admission date of 8/18/19, with diagnoses that included Alzheimer's Disease (a progressive disorder that affects memory, thinking, and behavior), Parkinsonism (movement disorder which…

    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 · Past Non-Compliance
  • Actual harm · Gcited before2025-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, investigation documents, and clinical records, and staff interviews, it was determined that the facility failed to maintain a safe environment regarding mechanical lift sling sizing for one of three residents that utilize a mechanical lift reviewed (Resident R46), that resulted in actual harm and required staple repair for a head laceration. Findings include: The facility's policy Safe Resident Handling/Transfers, dated 1/14/25, indicated that residents are to be transferred safely to prevent or minimize risks for injury. The policy further indicated that the facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per manufacturer's instructions on proper sling sizing. Review of Resident R46's clinical record revealed an admission date of 10/08/20, with diagnoses that included respiratory failure, heart failure, anxiety (a condition that causes a person to be nervous, uneasy,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-06 · tag F0565 — failed to support the resident council — pattern
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, review of facility policy 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 minutes for three of three months reviewed (November 2025, December 2025, and January 2026).Findings include: Review of a facility policy entitled, Resident Council dated 1/28/26, indicated that a Resident Council Response Form will be utilized to track issues and their resolution and the facility department related to any issues will be responsible for addressing the item(s) of concern. During an interview on 2/04/26, at 10:45 a.m. Resident Council Members (Residents R5, R56, R58, R67, R79, and R86) confirmed they do not receive responses to previous Resident Council concerns and do not believe Resident Council concerns are resolved in a timely manner due to the number of ongoing concerns voiced by the group. Review of November 2025, Resident Council Meeting Minutes revealed: new…

    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 · E2026-02-06 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documents, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents access to petty cash on an ongoing basis, and to ensure have access to their funds from the resident's petty cash fund the same day for amounts less than $100.00 ($50.00 for Medicaid residents) and on weekends for all 89 of 89 residents in the facility. Findings include: Review of the facility Admissions Agreement Section 18 (iv) page 22 revealed the facility shall provide cash, if requested within one day of the request or a check, if requested within three days of the request. During interviews on 2/04/26, at 10:45 a.m. Residents R5, R56, R58, R67, R79 and R86 confirmed that they cannot access petty cash on the same day during the week and not at all on weekends. Residents stated that they must give at least 24-hour notice of cash requests to allow the Nursing Home Administrator (NHA) time to go to the bank. During an interview on 2/04/26, 1:15 p.m. the NHA confirmed the cash box contains $400 and is kept in the Business Office.…

    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 · E2026-02-06 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment for multiple resident rooms on the first floor (101, 102, 103, 104, 105, 107, 108, 109, 111, and 113) and multiple resident rooms on the third floor (303, 304, 305, 309, 316 and 317).Findings include:Review of facility policy entitled Homelike Environment dated 1/28/26, indicated residents are provided with a safe, clean, comfortable and homelike environment.Review of the facility admission Agreement page 10 revealed that the facility will provide clean lodging.A facility document entitled, Room Cleaning Process revealed that daily housekeeper tasks included remove trash, sweep/mop floor, clean bathroom surfaces then toilet, and sweep/mop bathroom.Observations on 2/03/26, between 10:50 a.m. and 1:15 p.m. and on 2/04/26, between 8:45 a.m. and 9:30 a.m. revealed resident Rooms 101, 102, 103, 104, 105, 107, 108, 109, 111, and 113 to have a removable build-up of a black substance…

    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 · E2026-02-06 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility 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), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital, for four of four residents reviewed (Residents R11, R12, R76, and R90).Review of facility policy entitled Transfer and Discharge dated 1-28-26, indicated Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. And For a transfer to another provider, for any reason, the following information must be provided to the receiving provider:Contact information of the practitioner who was responsible for the care of the residentResident representative information, including contact informationAdvance directive informationAll other information necessary to meet 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to maintain proper care of respiratory equipment and failed to provide oxygen according to physician's orders for seven residents reviewed for respiratory care (Residents R12, R19, R22, R25, R56, R50, and R29). Findings include: Review of facility policy entitled Oxygen Administration dated 1/28/26, indicated Oxygen is administered under orders of a physician., and Keep delivery devices covered in plastic bag when not in use. Review of Resident R12's clinical record revealed an admission date of 10/9/24, with diagnoses that include chronic respiratory failure (a condition where your lungs don't exchange air properly), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R12's physician orders revealed an order for Oxygen at two liters/minute via nasal cannula (a thin…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-06 · tag F0711 — pattern
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 the physician signed and dated all orders during visits for nine of 21 residents reviewed (Residents R4, R7, R10, R18, R19, R22, R23, R58, and R67). Findings include: Review of facility policy entitled Physician Visits and Physician Delegation dated 1/28/26, revealed The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law. Sign and date all orders. Review of resident R4's clinical record revealed an admission date of 11/26/18, with diagnoses that included Alzheimer's disease (a progressive disorder that affects memory, thinking skills, and ability to perform simple tasks), diabetes (a chronic disease where the body does not produce enough insulin or cannot use it efficiently), and muscle weakness. Review 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy on one of five medication carts (Third floor 100 hall medication cart).Review of facility policy entitled Confidentiality of Information and Personal Privacy dated 1/28/26, revealed Ensure computer screens are in privacy mode or hidden when administering medications. Observations on 2/3/26, between 12:30 p.m. and 12:50 p.m. of the Third floor 100 hall medication cart revealed the medication cart sitting in the hallway against the wall with an open computer on top of the medication cart and resident health information visibly facing into the hallway. Continued observations revealed Licensed Practical Nurse (LPN) Employee E2 returned and walked away from the medication cart several times leaving resident health information visible while several visitors, residents and staff walked past the viewable health record. During an interview on 2/3/26, at 12:50 p.m. LPN Employee E2 confirmed that he/she left the medication cart with the computer open 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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 evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of 21 residents reviewed (Resident R4). Findings include: Review of facility policy entitled Psychotropic Medication Use dated 1/28/26, revealed that non-pharmacological approaches are used to minimize the need for medications, permit lowest possible dose, and allow for discontinuation of medications when possible. Review of Resident R4's clinical record revealed an admission date of 11/26/18, with diagnoses that included Alzheimer's disease (a progressive disorder that affects memory, thinking skills, and ability to perform simple tasks), diabetes (a chronic disease where the body does not produce enough insulin or cannot use it efficiently), and muscle weakness. The clinical record revealed that on 12/2/25, Resident R4's physician…

    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 · D2026-02-06 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 the resident's initial visit was conducted by the physician and that the physician alternate required resident visits with the nurse practitioner or physician's assistant for two of 21 residents reviewed (Residents R22 and R29).Findings include: Facility policy entitled, Physician Visits and Physician Delegation dated, 1/28/26, revealed that the physician should: see the resident within 30 days of initial admission to the facility; date, write, and sign a progress note for each visit; at the option of the physician, required visits in skilled nursing facilities, after the initial visit, may alternate between personal visits by the physician and visit by a physician assistant, nurse practitioner, or clinical nurse specialist. Resident R29's clinical record revealed an admission date of 1/13/26, with diagnoses including Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood), heart failure, difficulty…

    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 · Dcited before2026-02-06 · 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

    Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of three medication carts reviewed (First floor rehab and Second floor medication carts) and failed to prevent the opportunity for potential unauthorized access of medications on one of five medication carts observed (Third floor 100 hall medication cart).Review of facility policy entitled Administering Medications date 1/28/26, revealed When opening a multi-dose container, the date opened is recorded on the container. and During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. and The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Review of facility policy entitled Labeling of Medications and Biologicals dated 1/28/26, revealed Labels for multi-dose vials must include: The date the vial was initially opened or accessed. Review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2026-02-06 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and failed to maintain sanitary conditions in one of three pantry refrigerators (First floor). Findings include:Review of a facility policy entitled, Dietary-Food Receiving and Storage dated 1/28/26, revealed that All foods stored in the refrigerator or freezer will be covered, labeled and dated. The policy also indicated that dining services, of other designated staff, will maintain clean food storage areas at all times. Observation on 2/03/26, at 9:30 a.m. in the main kitchen walk in cooler revealed two 48-ounce bottles of salsa, three 16 ounce jars of parmesan grated cheese and one bottle of sweet relish, all with no open dates. During an interview on 2/03/26, at 9:45 a.m. the Dietary Manager confirmed that the above food items should have been dated when opened. Observation on 2/03/26, 10:45 a.m. of the pantry refrigerator on First Floor revealed it had brown/tan dried…

    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 · Dcited before2025-12-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records and facility policy, and staff interviews, it was determined that the facility failed to accurately transcribe a physician's order to promote comfort during care and/or prevent discomfort for one of three residents reviewed (Resident R1). Findings include: Review of facility policy entitled Medication Orders dated 1/14/25, revealed PRN Medication Orders - When recording PRN medication orders, specify. the reason for administration. Review of facility policy entitled Medication and Treatment Orders dated 1/14/25, revealed Orders for medications must include. symptoms for which the medication is prescribed. Review of Resident R1's clinical record revealed an admission date of 5/28/21, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically)and hypertension (high blood pressure). Review of hospice physician's order dated 10/12/25, revealed an order to pre-medicate (premed) prior to care with Ativan…

    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 · D2025-12-04 · 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 review of clinical records and facility policy, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding oral hygiene for one of three residents reviewed (Resident R1).Findings include: Review of facility policy entitled Mouth Care dated 1/14/25, revealed Documentation -The following information should be recorded in the residents clinical record: The date and time the mouth care was provided. Review of Resident R1's clinical record revealed an admission date of 5/28/21, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically) and hypertension (high blood pressure). Review of Resident R1's task (charting area in the clinical record where nursing assistant's document) under section GG oral hygiene every shift revealed that for day shift on 10/1/25, 10/4/25, 10/14/25, there lacked documentation that oral care was completed. On evening shift 10/2/25, 10/11/25,…

    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 before2025-02-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 the main kitchen, and resident pantries (First and Third floor). Findings include: Review of facility policy entitled Dietary-Food Preparation and Service dated 1/14/25, indicated Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Review of facility policy entitled Labeling and dating procedure for food and beverage dated 2/14/25, indicated We now have a total of 5 days to keep foods that are taken out of their original package. A product that is left in its original container can be used up to 7 days or the use by date whichever comes first. and The day that you open something is day 1 . Review of facility policy entitled Dietary-Food Receiving and Storage dated 2/14/25, indicated All foods belonging to residents must be labeled 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 · D2025-02-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days for one of five residents reviewed for psychotropic medications (Resident R17). Findings include: Review of facility policy entitled Use of Psychotropic Medications dated 1/14/25, indicated PRN orders for psychotropic medications . shall be limited to no more than 14 days . The medical record should include documentation from the physician or prescriber for the rational for the extended time period and indicate a specific duration. Review of Resident R17's clinical record revealed an admission date of 9/29/23, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), heart failure (a condition where the heart cannot supply the body with enough blood), and chronic obstructive pulmonary disease (when your lungs do not have adequate air flow). Review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · 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 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) vial with the date it was opened and discard an expired multi-dose insulin vial in one of seven medication carts (Third floor cart A). Findings include: Review of the facility policy entitled Multi-Dose Vials dated [DATE], indicated multi-dose vials will be labeled with date open. It also indicated that insulin expires 28 days from the opened date. Observation on [DATE], at 9:10 a.m. revealed the Third-floor medication cart A contained a vial of opened undated Novolog insulin in a bag with an expiration date on the outside of the bag of [DATE]. Observation on [DATE], at 8:10 a.m. revealed the Third-floor medication cart A contained a bag with an expiration date of [DATE], on the outside of the bag contained two vials of opened Novolog insulin both were undated. During an interview at that time, LPN Employee E5 confirmed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-31 · tag F0755 — failed to provide safe pharmacy services — pattern
    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 review of facility policy and clinical records, it was determined that the facility failed to ensure the timely availability of medication for three of three residents reviewed (Residents R1, R2, and R3). Findings include: Review of the facility policy entitled Specialty RX Policies and Procedures Pennsylvania dated 5/15/24, revealed . Each facility has routine deliveries to meet the facility's needs and ensure timelines of medication availability . Specialty Rx, Inc. pharmacies provide emergency deliveries of medication during and after normally scheduled hours of pharmacy operation and to ensure the customer is provided medications and care as ordered by the physician. A stat medication refers to a new medication ordered by the physician or a true stat that is not available in the facilities Back-up box or E-kit to provide medications in a timely manner by utilizing satellite (back-up) pharmacies to dispense medications that are needed by a facility sooner than the facility's regularly scheduled delivery Resident R1's clinical record revealed an admission date of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and facility documents, and staff interview, it was determined that the facility failed to failed to provide the highest practicable care regarding correct medication administration for one of six residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 6/05/24, with diagnoses that included diabetes, kidney disease and high blood pressure. Clinical record review for Resident R1 documented that on 6/25/24, at 11:55 p.m. Resident R1 was observed to be clammy and sweaty with a low blood glucose (sugar) level. Review of a facility investigation medication error document, dated 6/26/24, revealed that Resident R1 used Novolog 70/30 mix insulin (a mix of two types of insulin-a medication used to maintain blood glucose at normal levels) at home, but that he/she was administered Novolog (a single type of insulin) following admission to the facility. Physician orders dated 6/26/24, directed that the Novolog insulin be replaced 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 observations, clinical record review, and staff interviews, it was determined that the facility failed provide an environment that enhances resident's quality of life for one of 22 residents reviewed (Resident R37). Findings include: Review of Resident R37's clinical record revealed an original admission date of 2/23/18, with diagnoses that included dementia, Type 2 Diabetes (condition of improper insulin levels that affects how the body uses blood sugar), heart failure, post traumatic seizures, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and traumatic brain injury. A departmental progress note dated 11/03/23, indicated that Resident R37 enjoys watching TV and spending time in the common areas on his/her neighborhood. Observation on 3/26/24, at 2:15 p.m. Resident R37 was sitting alone in his/her room yelling out for help. During an interview at the time of the observation, Resident R37 confirmed he/she wanted someone to visit with him/her and expressed interest in going out to the lounge to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical and facility records, and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall for two of 18 residents reviewed (Residents R26, R37). Findings include: Review of facility policy Wheelchair, Geriatric Chair, Broda Chair, Misc. Resident Transport Chair Safety, dated 7/24/23, indicated Foot rests must be used when staff are assisting residents who are transported by wheelchair and, Broda chair or any chair with attachable footrests to prevent accident/injury unless resident is able to self propel. Review of Resident R26's clinical record revealed an admission date of 10/04/23, with diagnoses that included calculus of ureter (a formation kidney stones in a tube that urine passes from kidneys to bladder), neutropenia (a type of white blood cell and is at a low level in the blood), cystitis (infection of bladder), and muscle weakness. Review of the Minimum Data Set (MDS-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 · D2024-03-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of 18 residents reviewed (Resident R62). Findings include: Review of facility policy entitled Emptying a Urinary Drainage Bag (a bag that holds urine that comes from a tube placed and held in the bladder to drain urine), dated 7/24/23, indicated to keep the drainage bag and tubing off the floor at all times . Review of Resident R62's clinical record revealed an admission date of 12/17/23, with diagnoses that included urinary tract infection (an infection in any part of the urinary system), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of Resident R62's Quarterly Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated 2/1/24, revealed that Resident R62 had an indwelling urinary catheter. Observation on 3/27/24, at 8:50 a.m. revealed Resident R62's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-02-06 · tag F0841 — widespread
    Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of the Medical Director agreement, facility records, and staff interview, it was determined that the facility failed to ensure that the Medical Director fulfilled his/her responsibilities to develop, review, and improve resident care policies.Findings include:Review of the Medical Director agreement revealed he/she is expected to guide, approve, and help oversee the development, implementation, and monitoring/evaluation of the facility's resident care policies and procedures in several areas.Review of facility's annual policy reviews dated 1/28/26, revealed no signature by the Medical Director.Interview with the Nursing Home Administrator on 2/6/26, at approximately 12:12 p.m. revealed that the Medical Director was not present at the facility throughout the year to fulfill his/her responsibility in the development, review, and improvement of resident care policies and the Medical Director was not a part of the annual policy review. Refer to F711, F712, and F86828 Pa. Code 201.18(e)(1)(3) Management28 Pa. Code 211.10(c)(d) Resident care policies

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-02-06 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, facility records, and staff interview, it was determined that the facility failed to ensure the required attendance of the Medical Director or his/her designee to Quality Assurance and Performance Improvement (QAPI) Committee meetings for four of four quarterly QAPI Committee meetings reviewed.Findings include: Review of facility policy entitled Quality Assurance and Performance Improvement dated 1/28/26, revealed The QAA Committee shall be interdisciplinary and shall consist at a minimum of . The Medical Director or his/her designee. Review of the QAPI Committee Attendance Records from March 2025, through December 2025, revealed no evidence on the attendance sign-in sheets for all required QAPI meetings that included the Medical Director or his/her designee was in attendance. During an interview on 2/06/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed the facility lacked evidence that the Medical Director or his/her designee attended the Quarterly QAPI Committee meetings as required.Refer to F84128 Pa. Code 201.18(e)(1)(3)…

    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
  • No harm found · B2026-02-06 · tag F0641 — pattern
    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 review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) and failed to ensure that the MDS assessment accurately reflected the status for three of 21 residents reviewed (Residents R11, R23 and R90).Findings include:Review of Resident R11's clinical record revealed an admission date of 2/13/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs), and hypertension (high blood pressure). Review of Resident R11's physician orders revealed an order for hospice with a start date of 12/30/25. Review of Resident R11's MDS dated [DATE], section O special treatments, procedures, and programs under O0110 hospice revealed Resident R11 was inaccurately coded yes. Review of Resident R23'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.

    Resident Assessment and Care Planning 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

$14,015 in federal fines across 1 penalty.

  • $14,015 — penalty dated 2025-02-26

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

Part of a chain

This home belongs to ABRAHAM SMILOW — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.4+0.6 vs chain
Health inspection 2 of 51.4+0.6 vs chain
Staffing 2 of 51.9+0.1 vs chain
Quality measures 2 of 52.9-0.9 vs chain
The other 6 homes this chain runs (chain average 1.4★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Investor-owned

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

  • LADS AVENUE ASSOCIATES LLC — private equity · 1.49% share · 5% Or Greater Indirect Ownership Interest

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

Owner / managerTypeRoleShareSince
OAKWOOD HEIGHTS SNF OPCO HOLDCO COMPANY LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/15/2023
OAKWOOD HEIGHTS SNF PROPCO HOLDCO COMPANY LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 08/15/2023
SMILOW, ABRAHAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL95%since 08/15/2023
CAIN, PAULIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
ROHRBACH, CHARLESIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2023
LADS AVENUE ASSOCIATES LLCOrganizationADP OF THE SNFsince 08/15/2023
OAKWOOD HEIGHTS PROPCO COMPANY LLCOrganizationADP OF THE SNFsince 08/15/2023
T3 REAL ESTATE INITIATIVES LLCOrganizationADP OF THE SNFsince 08/15/2023
TRAVITSKY, BARUCHIndividualADP OF THE SNFsince 08/15/2023

CMS files one row per role, so the 17 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$6.2M
Net patient revenuemost recent cost report
-2.2%
Operating marginrevenue minus expenses
$259K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 80%Medicare 3%Other / private 17%

About 80% 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 $259K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$307per resident / day
operating cost
$9,340per month
≈ monthly operating cost
$300per 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 395502. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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