Seton Manor Nursing And Rehabilitation Center
1000 Seton Drive, Orwigsburg, PA 17961 · For profit - Corporation · 129 certified beds · (570) 366-0400 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.0% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.1% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.7% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.3% | 10.8% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.4% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.9% | 17.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 34.3% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 84.8% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 6.9% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 34.0% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.1% | 17.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.5% | 68.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.9% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.6% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.20 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.33 | 1.18 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 266 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.2% 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 83 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.3%CMS range 43.9–55.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.6–14.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 42.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 48.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 4.3–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 129 beds and averages 115.6 residents a day — about 90% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.94 hrs/resident/day on weekends vs 3.36 on weekdays — 12% thinner on weekends. RN hours go from 0.55 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · F2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, facility policy review, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dry storage area of the kitchen, and in nursing unit nourishment rooms and refrigerators. (Long Term Care, Rehabilitation, and Memory Care) Findings include: Review of the facility policy entitled, Foods Brought by Family/Visitors, dated December 17, 2025, revealed that food left for the resident to consume later would be labeled in a manner that was clearly distinguishable from facility-prepared food, and nursing staff were to label items with the resident's name, item and the use by date. It was then to have been discarded after five days. Observations during tours of the kitchen revealed the following: On February 10, 2026, at 10:20 a.m., in the food preparation area, a measuring cup was observed inside a bulk container of modified food starch with an unsealed, loose-fitting lid. On February 11, 2026, at 11:35 a.m., the bulk container of modified food starch still had an unsealed, loose-fitting lid. In the dry…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to follow physician's orders for four of 24 sampled residents. (Residents 4, 7, 15, 38)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included a history of a stroke, aphasia (impaired speech production and language comprehension), and dysphagia (difficulty swallowing). The Minimum Data Set assessment, dated January 21, 2026, indicated that the resident had an enteral feeding tube (a tube inserted into the abdomen to use for nutrients, medications, and fluids directly to a person's gastrointestinal system). A physician's order dated January 20, 2026, directed staff to flush the enteral feeding tube with 100 milliliters (ml) of water every six hours. Observations on February 11, 2026, at 12:25 p.m., revealed that Resident 4 was in bed and connected to a programmable enteral feeding pump system with nutrients and water running. A date on the disposable equipment revealed this feeding was set up February 11, 2026, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide care and services in a manner that maintained each resident's dignity for two of 25 sampled residents. (Residents 10, 88)Findings include: Clinical record review revealed that Resident 10 had diagnoses that included a history of a stroke resulting in upper and lower extremity weakness to the dominant side of the body, aphasia (impaired speech production and language comprehension), and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) assessment, dated December 16, 2025, indicated that the resident was cognitively impaired, had functional impairment of the dominant side limbs, and required supervision or assistance from staff to eat in the form of intermittent cueing or steadying. Review of the resident's care plan revealed that Resident 10 required set up and supervision at all meals, was to have a plate guard at meals, and all supplies would be placed within reach.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of six nursing units. (B, C, D, and H)Findings include:Observations on February 10, 2026, from 11:01 a.m. through 2:10 p.m. and on February 10, 2026 from 10:00 a.m. through 12:00 p.m. revealed the following: A grey substance was observed covering the exhaust vents in the central bathing rooms in nursing units C and H. The cover was off and a grey substance was observed covering the filters of the heating/air conditioning units in resident rooms 503, 505, 603, and 705.The door was damaged on resident rooms [ROOM NUMBERS].A broken floor tile was observed in the doorway of resident room [ROOM NUMBER].A grey substance was observed on the filters of the oxygen concentrators in rooms [ROOM NUMBERS].28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management.
- Potential for harm · D2026-02-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling catheter. (Resident 4) Findings include: Review of the facility policy entitled, Urinary Catheter Care, last reviewed December 17, 2025, revealed that the urinary drainage tubing should be checked to ensure that the catheter is draining properly. Clinical record review revealed that Resident 4 had diagnoses that included history of a stroke and dysfunction of the bladder. The Minimum Data Set assessment, dated January 21, 2026, indicated that the resident had an indwelling urinary catheter for urine elimination. On January 19, 2026, the physician ordered for the resident to have an indwelling urinary catheter. Review of the resident's care plan revealed that Resident 4's catheter bag and tubing were to be positioned below the level of the bladder. Observations on February 11, 2026, at 12:20 p.m. and 2:20 p.m., revealed that Resident 4 was in bed with the urinary catheter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 and resident and staff interview, it was determined that the facility failed to ensure a call bell was accessible for one of 25 sampled residents. (Resident 96) Findings include: Clinical record review revealed that Resident 96 had diagnoses that included left hip fracture, Parkinson's disease (a movement disorder that affects the nervous system and causes tremors and stiffness of the body), and anxiety. Review of the Minimum Data Set (MDS) assessment, dated February 12, 2025, revealed Resident 96 was alert and oriented and dependent on staff for Activities of Daily Living (ADL's), including toileting, dressing, and personal hygiene. Review of the care plan revealed that Resident 96 was at risk for falls with an intervention for staff to check that the call bell was in reach before leaving the room. On March 5, 2025, at 9:36 a.m., Resident 96 was observed in bed with the call bell on the floor next to the bed, out of reach. In an interview at that time, Resident 96 stated that the call bell could not be reached and that he did not have it for the last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 provide services to maintain adequate grooming and hygiene for two of 25 sampled residents who required assistance with activities of daily living (ADLs). (Residents 42 and 96) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included ambulatory dysfunction, muscle weakness, and osteoarthritis. Review of the care plan revealed that the resident required assistance from staff for ADLs. On March 4, 2025, at 12:30 p.m., the resident was observed eating his lunch in bed. His fingernails were long, pointy, and sharp. On March 6, at 12:40 p.m., the resident was observed sitting up in bed with his nails still uncut. In an interview at that time, Resident 42 stated he would like his nails cut, and staff has not offered to do them. There were no documented refusals. Clinical record review revealed that Resident 96 had diagnoses that included Parkinson's disease (a movement disorder that affects the nervous system and causes tremors…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that the environment was free of accident hazards on one of three nursing units, (Cloister nursing unit) and for one of three residents who were confused and ambulatory on the nursing unit. (Resident 1) Findings include: Clinical record review revealed that Resident 1 resided on the Cloister nursing unit which is a locked dementia unit. Resident 1 had diagnoses that included dementia with anxiety and behavioral disturbance, mental disorder and depression. The Minimum Data Set assessment dated [DATE], indicated that the resident had cognitive impairment and exhibited physical, verbal and other types of behaviors that included hitting and/or grabbing at least one to three times a week. A review of the care plan revealed that the resident was at risk of attempting to eat or drink non-edible or non-consumable items. Review of nursing documentation revealed that Resident 1 was independently…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-08 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review and clinical record review, it was determined that the facility failed to promptly notify a resident's physician of change in condition for one of four sampled residents. (Resident CR1) Findings include: A review of the facility policy entitled, Change in a Resident's Condition or Status, last reviewed December 27, 2023, revealed that staff were to promptly notify the physician if there was a change in medical condition. Clinical record review revealed that Resident CR1 had diagnoses that included heart failure, dementia, and atrial fibrillation (irregular heart rhythm). A physician's order dated October 26, 2024, directed staff to administer a medication, (Eliquis) two times a day to prevent blood-clots. On November 5, 2024, at 4:05 a.m., a nurse documented that Resident CR1 had fallen that morning at 3:10 a.m. The resident sustained a large hematoma (localized collection of clotted blood) with a lump to the right side of her forehead. According to the nurse's note at 4:10 a.m., the resident complained of pain and was medicated with Tylenol. There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-26 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that a dignified environment, care, and services were provided to promote quality of life on three of three nursing units and in the dining room for four residents in one of three dining rooms. (Resident 1, 9, 64, 95) Findings include: Observation on the Cloister nursing unit on April 23 and 24, 2024, revealed a white board in the dining room displaying the date of April 20, 2024, and activities listed for that day. Observation on the Sub-Acute nursing unit on April 23 and 24, 2024, revealed the white boards in the residents' rooms displaying the date of April 20, 2024, and the staff listed for that day. Clinical record review revealed that Resident 1 had diagnoses that included dementia and depression. Review of Resident 1's current care plan revealed that the resident was on a restorative nursing program for dining and needed supervision and occasional assistance with meals. Observation 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.
Show the remaining 7 citations
- Potential for harm · Ecited before2024-04-26 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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, review of facility documentation, and staff and resident interview, it was determined that the facility failed to accommodate resident needs in a timely manner by responding to the call bell system for one of three nursing units. (Long Term Care unit) Findings include: Clinical record review revealed that Resident 76 had diagnoses that included paraplegia (paralysis), dysphagia (difficulty swallowing), anxiety, and depression. According to the Minimum Data Set assessment, dated May 16, 2024, the resident had no cognitive impairment. Review of the care plan revealed that the resident was at risk for falls and that staff was to keep the call bell within reach and encourage it's use because the resident needed prompt response to all requests for assistance. On April 23, 2024, at 10:30 a.m., the resident was observed in bed with the call bell activated. In an interview at 10:51 a.m., Resident 76 stated she had been waiting to get up for the day and no one answered her call bell. Resident 76 also stated at that time, that she often waits…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — 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 resident representative of a change in condition for one of 27 sampled residents. (Resident 34) Findings include: Clinical record review revealed that Resident 34 had diagnoses that included diabetes, soft tissue disorders, and adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set assessment, dated February 5, 2024, revealed the resident had cognitive impairment. Review of a nurse's note dated April 20, 2024, revealed that Resident 34's lower left leg was observed to be red and warm with new orders from the physician for doxycycline (antibiotic) and a venous doppler (ultrasound to evaluate blood flow). There was no documented evidence that the resident's representative was notified of the change in condition. In an interview on April 26, 2024, at 10:45 a.m., the Administrator confirmed that the resident's representative was not notified of the change in condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
- Potential for harm · D2024-04-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 27 sampled residents. (Resident 45) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included anxiety, bipolar disorder, and Parkinson's disease. The Minimum Data Set (MDS) assessment completed on August 1, 2023, indicated the resident had moderately severe depression. According to the Care Area Assessment summary from that assessment, the facility identified that mood state was a problem area for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area. In an interview on April 26, 2024, at 11:33 a.m., the Director of Nursing confirmed that Resident 45's care plan did not include the area of potential concern identified in the comprehensive assessment. 28 Pa. Code 211.12(d)(5) Nursing services.
- Potential for harm · D2024-04-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess and document the status of wounds for one of four sampled residents with wounds. (Resident 28) Findings include: Review of the facility policy entitled, Skin Management Guidelines, last reviewed December 27, 2023, revealed that staff was to evaluate and document wound status weekly. Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnoses that included a sacral pressure sore and congestive heart failure. Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 28 had a Stage 3 pressure sore since admission to the facility. Review of the nursing notes revealed that the resident was being treated for a pressure sore to their sacrum. Review of Resident 28's skin and wound evaluation records revealed that there was no documented evidence that staff assessed the resident's wounds the weeks of January 28, 2024, February…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 clinical record review and observation, it was determined that the facility failed to provide adequate supervision to prevent accident/hazards on one of three nursing units. (Cloister unit) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired and needed staff supervision with eating. Review of the resident's current care plan revealed that Resident 9 was on a restorative nursing program for dining and staff was to supervise and provide cueing. Observation on April 23, 2024, from 12:25 p.m. through 12:55 p.m., revealed Resident 9 eating in the dining room on the nursing unit. During this time Resident 9 was observed mixing straw wrappers, creamers, and salt and pepper packets in with her food. Resident 9 took her menu, straw wrapper, and spaghetti noodles and put them in her cup of coffee and proceeded to drink from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2026-02-12 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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, review of facility documentation, and resident and family interviews, it was determined that the facility failed to follow the planned menu and ensure that preferences were provided for four of 24 sampled residents. (Residents 1, 10, 14, 84) Findings include: Review of the facility menu revealed that the lunch meal on February 11, 2026, was to be baked ham, sweet potatoes, Italian green beans, and gelatin with whipped topping. Clinical record review revealed that Resident 1 had diagnoses that included moderate protein calorie malnutrition, epigastric pain, and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 1 had no cognitive impairment. In an interview on February 11, 2026, at 12:17 p.m., Resident 1 stated that she did not receive what was on the menu or what she preferred. Resident 1's responsible party was present and confirmed Resident 1's statement. Observations at that time revealed Resident 1 received a grilled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-03-07 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on March 4, 2025, at 10:30 a.m., revealed one of the lids on top of the dumpster was crooked and not covering the top. There were multiple pieces of crushed plastic and paper debris and used gloves around the outside of the dumpster. In front of the dumpster, there was an area with smashed carrots. There was a bag covered with a brown substance that was wedged below the dumpster and sticking out with gauze debris around it. Behind the dumpster, there was a large piece of meat that was covered with a white substance. 28 Pa Code 201.18(b)(3) Management.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to IMPERIAL HEALTHCARE GROUP — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.3 | +1.7 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 1.3 | +0.7 vs chain |
| Quality measures | 2 of 5 | 3.3 | -1.3 vs chain |
The other 8 homes this chain runs (chain average 2.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BH OPCO HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2022 |
| CHRH EQUITIES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 07/29/2021 |
| ENS HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 07/29/2021 |
| THE ENS FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 07/29/2021 |
| YMCS EQUITIES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 07/09/2021 |
| GOTTESMAN, DANIEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 07/29/2021 |
| GROVE, JOSHUA | Individual | W-2 MANAGING EMPLOYEE | — | since 07/01/2019 |
| HERZKA, YISROEL | Individual | CORPORATE OFFICER | — | since 07/29/2021 |
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.
About 75% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 396063. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.