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Laurel Square Healthcare And Rehabilitation Center

1020 Oak Lane Avenue, Philadelphia, PA 19126 · For profit - Limited Liability company · 87 certified beds · (215) 224-9898 Medicare & Medicaid certified

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1 immediate-jeopardy citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection 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.

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

Location & what’s nearby

Hospital
Urgent care / clinic
921 W Cheltenham Ave · (215) 635-4902 · Call to confirm hours
Pharmacy
416 Oak Lane Rd · (215) 444-7525 · Call to confirm hours
Grocery
101 Cheltenham Ave · (215) 782-3880 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 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 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 increased14.7%16.8%15.4%typical
Long-stay residents who lose too much weight9.3%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder2.3%0.7%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms0.3%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.8%3.1%3.3%better
Long-stay residents whose ability to walk worsened14.3%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.0%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine84.6%93.5%95.3%worse
Long-stay residents with pressure ulcers4.2%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control28.9%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.7%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication4.2%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine5.9%68.7%79.4%worse
Short-stay residents rehospitalized after admission29.4%22.5%22.6%worse
Short-stay residents with an outpatient ER visit6.3%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days3.761.621.67worse
Long-stay outpatient ER visits per 1,000 resident days1.711.181.80typical

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

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

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

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

43.9% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.9%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
40.6%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 40.6% 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 32 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.9%CMS range 31.6–58.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.8–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge40.6%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 discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.5%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 identified98.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or 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 hospitalization6.0%CMS range 2.9–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.60
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.41
RN hoursweekends
51.4%
Total nursing turnover
52.4%
RN turnover

How full it usually is: this home is certified for 87 beds and averages 82.9 residents a day — about 95% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.37 hrs/resident/day on weekends vs 3.75 on weekdays — 10% thinner on weekends. RN hours go from 0.68 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

3
deficiencies at the latest standard inspection (2026-05-29)
8
at the previous standard inspection (2025-06-05)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · J2023-08-04 · 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 policies, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to adequately supervise one of three residents reviewed who exhibited elopement behaviors, resulting in Resident R1 eloping from the facility and found by medical personnel at a park the next day and taken to the local hospital. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. (Resident R1) Findings include: Review of the facility policy, Wandering and Elopements, with a revision date of March 2019 indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Continued review of the facility policy indicated that if a resident is identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of Resident R1's July 2023, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-05-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on standards of professional practice, observation, and interview with staff it was determined that the facility failed to store food in accordance with standards for food service safety (main kitchen and first floor nursing unit). Findings include: Review of Leftovers and Food Safety from the U.S. Department of Agriculture, Food Safety and Inspection Service, last updated July 2020 revealed leftovers can be kept in the refrigerator for 3 to 4 days. A tour of the main kitchen conducted on May 26, 2026, at 9:50 a.m. with the Food Service Director, Employee E10, revealed the following: Observations in the walk-in refrigerator revealed pre-prepared leftover pea puree, hot dogs, and beef gravy. The prepared date for each item was May 24, and use-by date of May 30. Further observations revealed a shrimp stir fry with a prepared date of May 20 and use-by date of May 26. All items were stored in stainless steel chafing steam table pans. Observations on May 26, 2026, at 11:00 a.m. revealed the ice machine on the first-floor nursing unit had a large, white plastic tray underneath it.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2026-05-29 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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

    Based on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to follow the planned menus for two of four days observed (5/26 and 5/28). Findings include: Review of the facility planned menu revealed for the week of 5/24/2026 revealed the lunch planned for Tuesday 5/26/2026 included green peas and cabbage as the main and alternate vegetable. Observations on May 26, 2026, at approximately 12:15 p.m. in the 1st floor dining room revealed the menu posted also indicated the vegetables were green peas and cabbage as the main and alternative vegetable. Interview on May 26, 2026, at 12:18 p.m. with Resident R52 revealed the facility frequently does not follow the planned menu. Interview on May 26, 2026, at 12:30 p.m. with Registered Dietitian, Employee E12, revealed he/she was unaware of any menu changes for the lunch meal on May 26, 2026. Interview on May 26, 2026, at 12:35 p.m. with Resident R63, revealed the facility does not serve what is on the planned menu. Observations on May 26, 2026, at 12:45 p.m. revealed R47…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2025-11-06 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of policy, and interview with staff, it was determined that facility did not develop and implement a baseline care plan for one out of six residents reviewed, related to bladder incontinence (Resident R2) Findings include:Review of facility policy ' Baseline Care Plans, ' revised March 2022, indicates that a baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight hours of admission. Review of Resident's R2 clinical record revealed the diagnoses of acute kidney failure with acute cortical necrosis, personal history of malignant neoplasm of prostate, obstructive and reflux uropathy, acute metabolic acidosis, artificial openings of urinary tract. Review of Resident R2's ' skin and wound note completed on August 11, 2025, at 4:00 pm, stated Resident R2 was incontinent with following recommendations: use appropriate moisture barrier creams per formulary to provide thorough skin care with each episode…

    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 · D2025-11-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and interview with residents and staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispense and administration of medication to meet the needs of a resident according to professional standards of practice relating to medication administration for 1 of 11 residents reviewed (Resident R1) Findings include:Review of the facility's policy titled Administering Medications last revised April 2019 states that medications are administered in a safe and timely manner, and as prescribed. Interview with Resident R1 on November 6, 2025, at 11:45 a.m. revealed that she had complained about her eye being red on October 22, 2025, and that the first time the eye drops were ordered they were lost by the overnight nurse, Employee E6. Then there was an issue getting the eye drops reordered due to a problem with the insurance not paying for the same prescription twice in one week. Resident R1 said that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-09-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policies, and staff and resident interviews, it was determined that the facility ensure that refrigerated food items were timely discarded to ensure food safety. Findings include:Review of the facility's policy titled Food Quality and Palatability, dated February 2023, revealed that food is to be prepared using methods that conserve nutritional value, flavor, and appearance. The policy states that food must be palatable, visually appealing, and served at a safe and appetizing temperature. Additionally, food and liquids are to be prepared and served in a manner, form, and texture that meets the individual needs of residents.Further review indicated that cooks are expected to prepare food in a sanitary manner, following the principles of Hazard Analysis Critical Control Point (HACCP) and adhering to time and temperature guidelines as outlined in the federal Food Code. Recipes are to be followed, and seasoning should reflect regional and ethnic preferences as appropriate.Review of the Food Storage and Retention Guide from Health Care Service…

    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 · Ecited before2025-07-08 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations of the noon meal service, reviews of food committee meeting minutes, reviews of policies and procedures and interviews with residents and staff, it was determined that foods and drinks were not appetizing, palatable and served at safe temperatures that were satisfactory to the residents. Residents: (R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R15 and R16) Findings include: A review of the facility policy and procedure titled healthcare services group dated June 23, 2025 revealed that it was the responsibility of the food and nutrition department to evaluate and test the teperature of the foods being served to the residents at point of service. Interview with the director of dietary services, Employee E6, at 1:00 p.m., on July 8, 2025 confirmed that the dietitian and the director of dietary services were responsibile for conducting routine temperature test trays at point of service to the residents. The test tray evaluations were used to monitor the safety and quality of the foods along with the timeliness of the food delivery system. The director of dietary,…

    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 · Fcited before2025-06-05 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure 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, facility policy, and interviews with residents and staff, it was determined that the facility failed to prepare and serve items as planned on the menu and failed to provide residents with their requested foods of preference for five of 18 residents interviewed (Residents R23, R28, R63, R70, and R289 ). Findings Include: Review of the facility posted Always Available menu posted in the first-floor dining/activities room lists beverages as Apple Juice, Cranberry Juice, Orange Juice, Hot Tea, Coffee, and Decaf Coffee. Review of facility policy titled, Therapeutic Diets revised September 2017 states, Polciy Statement- All residents have a diet order, including regular, therapuetic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practioner in accordance with applicable guidelines. Procedures- .3.Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized…

    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 · Fcited before2025-06-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety for three of three floors reviewed. (Ground, First, and Second Floors) Findings Include: Review of facility policy titled, Food Storage: Cold Foods revised April 2018 states, Policy Statement- All Time/Temperature Control For Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines for the FDA Food Code. Further review of the policy revealed, Procedures . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of facility policy titled, Food Storage: Dry Goods, revised September 2017 states, Procedures- . 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. 7. Toxic materials will…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-05 · 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 review of facility policies, observations and staff interview, it was determined that the facility failed to maintain a clean and homelike environment for two of two nursing units observed (First Floor and Second Floor Units). Findings Include: Review of facility policy titled, Homelike Environment revised February 21, 2025, states Policy Statement- Residents are provided with safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment; f. pleasant, neutral scents. Review of the facility policy titled, Resident Dining Room Meal Service dated December 2023 states, Policy Statement- The purpose of this policy is to facilitate a safe, comfortable, and resident centered dining experience. Procedure- 1. Dining room staff will perform hand hygiene. 2. Nurse Aides, will offer residents clothing…

    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 · E2025-06-05 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of eighteen residents reviewed (Resident R23 and Resident R80). Findings Include: Review of facility policy titled, Care Planning- Interdisciplinary Team, with a revision date of March 2022 states, Policy Statement- The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation- 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Review of facility policy titled, Bath, Shower/Tub revised October 2024 states, Purpose- the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe for condition of the resident's skin. Further review of 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · E2025-06-05 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on reviews of staff training and competency sets for nursing assistants, reviews of the facility assessment and interviews with staff, it was determined that, the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for two of four nurse aides personnel records reviewed. (Employees E12 and E13). Findings Include: Employee E12, nursing assistant was hired on July 25, 2025. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant. Employee E13, nursing assistant was hired on October 29, 2010. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency) were not documented 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interviews with resident and staff, review of clinical records and facility policies, it was determined the facility failed to ensure the rights of a resident were exercised to refuse a room change in accordance with professional standards of practice for one of 18 resident records reviewed (Resident R70). Findings Include: Review of the facility's policy titled, Resident Rights states, basic rights to all residents of the facility include exercising his or her rights and be supported by the facility in exercising those rights. Residents have the right to perform services for the facility if chooses or the right to refuse and the right to refuse a transfer from a distinct part within the institution. Review of the facility's policy titled, Transfer, Room to Room revised December 2016 states under Documentation The following information should be recorded in the resident's medical record: 1. The date and time the room transfer was made. 2. the name and title of the individual(s) who assisted in the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 — an excerpt from the official record, may be distressing

    Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of eighteen residents reviewed (Residents R50). Findings Include: Review of facility policy titled, Care Planning- Interdisciplinary Team, with a revision date of March 2022 states, Policy Statement- The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation- 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. A review of the clinical record for Resident R4 revealed an admission date of September 13, 2022, with diagnoses including Dementia (a progressive decline in cognitive abilities, including memory, language, and reasoning, that significantly impairs daily life and activities) with agitation. Review of Resident R4's current care plan 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding Include: Observations were made on the day of arrival to the facility, June 2, 2025 at 9:03 a.m. of the parking lot grass area where there were multiple trash items. Trash items in the grass and in the parking lot included; used paper towels, latex gloves, empty plastic bottles, plastic disposable utensils, and food particles. A tour of the Food Service Department was conducted on June 2, 2025, at 10:23 a.m., with the Food Director, Employee E9. In the area of the loading dock, refuse area one of two dumpsters was so full boxes were preventing the dumpster from completely closing. A toilet was near the dumpster area along with PVC piping that was once used at the facility. The Director could not say how long these items where there because he was not aware of the trash schedule. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility must ensure that residents who require colostomy services, received such care consistent with professional standards of practice and the comprehensive person-centered care plan, and the resident's goals and preferences for one of five residents reviewed. (Resident R1) Findings Include: According to guidelines from American Cancer Society for Caring for colostomy (A colostomy is an opening in the belly abdominal wall that's made during surgery. It's usually needed because a problem is causing the colon to not work properly, or a disease is affecting a part of the colon and it needs to be removed) , The skin around your stoma should always look the same as skin anywhere else on your abdomen. Use the right size pouch and skin barrier opening. An opening that's too small can cut or injure the stoma and may cause it to swell. If the opening is too large, output could get to and irritate the skin. In both cases, change the pouch or skin barrier and replace it with one that fits well. Change the pouching system regularly to avoid leaks and skin irritation. It's important 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-03 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    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 observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential equipment related to bathroom sink and ice and water dispenser on the first floor were in a safe and working condition for use by residents and nursing staff on one of two nursing units (Second Floor nursing unit). Findings include: Observation on December 3, 2024, at 10:45 a.m. in room [ROOM NUMBER] on the second-floor nursing unit revealed a sink with no fixtures (hot and cold water faucets and spout) were on the sink so that no water could be run to wash your hands. Interview with Resident R5, who lives in room [ROOM NUMBER], Bed A, revealed that the water in the sink has not been working for at least the past five days. She stated that she has to walk to the other end of the hall to go to the bathroom and wash her hands and to wash up in the morning. Interview with Resident R8, who lives in room [ROOM NUMBER], Bed C, revealed that she also has to walk to the other end of the hall…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews with resident and staff, it was determined that the facility failed to make a process available to allow residents to file a grievance anonymously on two of two nursing units. (First and Second Floor) Findings include: During a group interview conducted on September 10, 2024, at 1:30 p.m. with seven alert and oriented residents (R42, R7, R19, R63, R17, R73 and R11), the residents stated that they were not aware of how to file a grievance with the facility anonymously. All seven residents in attendance stated that they thought there should be a box with a lock so they could file a grievance anonymously if they wanted to. Observations of the nursing unit on the Frist and Second Floor and bulletin boards throughout the facility, conducted on the first two days of survey from September 9, 2024, through September 10, 2024, revealed no place to file an anonymous grievance. During an interview during a tour of the facility on September 11, 2024, at 9:15 a.m., the Social Services Director confirmed that there were no locked boxes on the nursing units 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 before2024-09-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 — 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, review of facility documentation, and review of clinical records, it was determined that the facility did not ensure to develop a person-centered, comprehensive care plan related to bowel obstruction and constipation for one of 19 residents reviewed (Resident R72) Findings include: Review of facility provided policy 'care plans, comprehensive person - centered,' revised March 2022, states that the comprehensive, person-centered care plan: e. reflects currently recognized standards of practice for problem areas and conditions. Review of Resident R72's clinical record revealed medical diagnosis of intestinal obstruction, retention of urine, ulcerative colitis, acute abdomen, nausea and vomiting, hemiplegia and hemiparesis following cerebral infarction (paralysis/weakness post stroke) on right side of body. Review of R72's hospital discharge documentation dated April 30, 2024 revealed Resident R72 presented to emergency room with 4 days of suprapubic abdominal pain 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 review of facility policy, review of facility documentation, review of clinical records and interview with residents, it was determined that facility did not ensure to assist dependent residents with activities of daily living related to hearing aids, nail care and hygiene care (Residents R2, R9) Findings include: Review of facility policy 'Care of Hearing Aid,' revised February 2018, indicates that nursing staff are to review resident's care plan to assess for any special needs of the resident, and if hearing aid is not functioning properly, check the battery. Review of Resident R89's care plan, revised on May 7, 2024, revealed Resident R9 has a communication problem related to hearing deficit, with intervention to ensure availability and functioning of adaptive communication equipment message board, hearing aids, telephone amplifier, computer, pocket talker, etc. Review of Resident R9's clinical record revealed an active physician order to assist resident with hearing aides at 6:00 AM. Observations of Resident R9 on September 9, 2024 at 11:42 AM revealed Resident R9…

    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 · D2024-09-12 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two of two residents receiving dialysis reviewed (Residents R54 and R7). Findings include: Review of Resident R54's clinical record revealed a physician's order for hemodialysis every Tuesday, Thursday and Saturday with a 10 a.m. chair time at a local dialysis center with transportation by local ambulance company. Further review of Resident R54's dialysis log record revealed that only two of five log pages were completed with two pages having no documentation from the dialysis center on the resident's clinical information. Interview with the Nursing Supervisor, Employee E12, on September 11, 2024, at 2:15 p.m. confirmed that the dialysis center had failed to complete the clinical documentation on two log pages for Resident R54. Review of Resident R7's clinical record revealed a physician's order for hemodialysis every Monday, Wednesday and Friday with a 2:45 p.m. chair…

    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 · D2024-09-12 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of yearly performance reviews for nurse aides for two out of five employees reviewed (Employee E13, E14) Findings include: On September 12, 2024, at 11:00 AM interviewed facility's human resources, Employee, E8, requesting evidence of yearly performance reviews for nurse aides. Per interview with facility's Director of Nursing, Employee E2, on September 12, 2024, at 12:00 PM, confirmed that Nurse aides, Employees E13 and E14 did not have performance evaluations/in-service education based on the outcome of these reviews completed. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility did not ensure to post nursing staffing information in a prominent place, readily accessible to residents on three of three floors observed. (Ground, First and Second floors) Findings include: Observation of the facility on September 10, 2024 and again on September 11, 2024 revealed the facility did not post the nurse staffing data at beginning of each shift, with complete and accurate information, in a visible place - accessible to residents and staff. Posted Nurse staffing information excluded required/actual nursing hours, adjusted census, and call outs. These findings were reviewed with the Human Resources, Employee, E8, on September 12, 2024 at 11:30 AM. 28 Pa Code 201.14(a)Responsibility of licensee 28 Pa Code 211.12(d)(1) Nursing services

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for seven of seven residents in the group meeting (R42, R7, R19, R63, R17, R73 and R11). Findings include: A review of Test Tray Form, revealed that the standard temperature for hot foods, including entrée, vegetable and starch, on tray line was 135 degrees and cold food, including milk and juice, was 41 degrees. During a group meeting with alert and oriented resident who regularly attend resident council meetings, all seven residents (R42, R7, R19, R63, R17, R73 and R11) indicated that the food is not very good, not cooked right, that residents often order out because they don't like the food, and that the food is often served cold. Observations during a test tray conducted with Employee E10, Assistant Food Service Director (AFSD), on September 11, 2024, at 12:05 p.m., revealed that the ham was at 128 degrees, the sweet potatoes were 133 degrees, and the orange juice…

    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 before2024-09-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The Policy: Food Storage, Cold Foods, which was revised February 2023, states, All foods will be stored wrapped or in covered container, labeled and dated, and arranged in a manner to prevent cross contamination. An initial tour of the Food Service Department was conducted on September 9, 2024, at 10:45 a.m. with Employee E9, Food Service Director (FSD), which revealed the following: Observations in the dry storeroom revealed that one ceiling tile was missing revealing pipes above and another ceiling tile which had a damp spot in the center. Further observation revealed metal wire shelving was pitted with rust colored and dark stains which was in front of the outer aluminum wall of the walk-in refrigerated units had a dark black substance growing up from the floor level to two to three feet high.…

    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 before2024-09-12 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area. Findings include: An initial tour of the Food Service Department was conducted on September 9, 2024, at 10:45 a.m. with Employee E9, Food Service Director (FSD), which revealed the following: Observation in the receiving area revealed the side sliding door to the garbage dumpster was open, and both top lids to the recycling dumpster were open due to too many boxes, including many boxes which were not broken down, which kept the lids from closing. Further observation revealed that there were nine wooden pallets haphazardly piled near the dumpsters. There were three wheelchairs and five over-bed tables in the area. Interview with FSD revealed that equipment was to be discarded and pallets were not from food or central supply as these items are hand carted from the driveway. Interview with the FSD on April 30, 2024, at 10:15 a.m. confirmed the above findings and that the equipment was to be…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for one of 18 residents interviewed(Residents R33). Findings include: Interview with Resident R33 in room [ROOM NUMBER], Bed A, conducted on September 9, 2024, at 11:15 a.m. revealed that his call bell does not work. Following the call bell cord from the button revealed that the plug on the other end was laying on the floor. Observations of the wall behind the bed did not reveal a plug in the wall for the plug and there was a hole in the wall where an outlet may have been. Observation of the call bell for bed B in room [ROOM NUMBER] revealed that the call bell was plugged into a box that was sitting on top of the overbed light and not attached to the wall. Interview with Employee E11, the Licensed Nurse, on September 9, 2024, at 11:20 a.m. confirmed that the call bell for room [ROOM NUMBER], Bed A was not plugged into an outlet, and that she had no…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-19 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 observations, review of facility provided documentation and interview with staff, it was determined facility did not ensure to implement resident-directed care and treatment consistent with professional standards of practice, placing the residents at risk for infections or accidents for two residents observed (Resident R4, R5) Findings include: Review of facility policy 'Bath, Bed,' revised on March 2021, indicates to empty and clean the wash basin with hot, soapy water, and return wash basin to designated storage area. Review of facility policy 'Shaving the Resident,' revised on February 2018, indicates that If using a safety or disposable razor .dispose of the razor in a designated sharps container. Review of facility policy 'Catheter Care, Urinary, revised on April 2024, indicates under infection control, to be sure the catheter tubing and drainage bag are kept off of floor. Observations on first floor unit of room [ROOM NUMBER] on August 19, 2024 at 11:00 AM revealed a used basin with used glove…

    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 · D2023-08-04 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding the elopement of one of three clinical records reviewed (Residents R1), which resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator (NHA) indicated that the purpose of the position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safety meet the residents' needs in compliance with federal, state and local requirements. Review of the job description for the Director of Nursing (DON) indicated that the purpose of the description is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department, in addition to assessing resident care needs, setting resident care standards in accordance with accepted current standards of care to provide…

    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 · C2026-05-29 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process.Findings Include: Review of facility documentation Facility Assessment reviewed February 11, 2026, revealed individuals who were involved in completing the review included: Nursing Home Administrator (Employee E1), Director of Nursing (Employee E2), Admissions Director (Employee E3), Business Office Manager (Employee E4), House Keeping Director (Employee E5), Rehabilitation Director (Employee E6), Human Resources (Employee E7), Dietary (Employee E8), and the Medical Director (Employee E9). Review of the facility assessment and the sign-in sheet for individuals involved in completing the annual review of the facility assessment revealed no documented evidence that the facility included active involvement from direct care staff (including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Nurse Aides (NA)). Further review of the facility…

    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 no plan 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to NATIONWIDE HEALTHCARE SERVICES — 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 52.6-0.6 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 3 of 52.9+0.1 vs chain
Quality measures 3 of 53.1-0.1 vs chain
The other 6 homes this chain runs (chain average 2.6★, 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 / managerTypeRoleShareSince
BRAUN, SHELDONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL5%since 10/08/2015
GELLEY, MEIRIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST90%since 10/08/2015
GELLEY, LEAHIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 10/08/2015
NATIONWIDE HEALTHCARE SERVICESOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/08/2015

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$9.2M
Net patient revenuemost recent cost report
-17.9%
Operating marginrevenue minus expenses
$1.4M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 5%Other / private 11%

About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$386per resident / day
operating cost
$11,735per month
≈ monthly operating cost
$327per 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 395535. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-29, 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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