Logan Square Rehabilitation And Healthcare Center
2 Franklin Town Blvd, Philadelphia, PA 19103 · For profit - Limited Liability company · 109 certified beds · (215) 563-1800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $43,154 in federal fines (most recent 2024-01-24)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.4% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.1% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 22.0% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.0% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.4% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 5.4% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 78.8% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.8% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.9% | 25.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.7% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 49.2% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.2% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.3% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.28 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.05 | 1.18 | 1.80 | worse |
§ 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.
33.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 434 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.5% 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 206 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 33.2%CMS range 28.9–38.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 9.3–13.7 | 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 | 65.5% | 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 | 65.5% | 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 | 61.2% | 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 | 99.7% | 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 | 99.1% | 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 | 96.9% | 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 | 1.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 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 | 8.1%CMS range 6.0–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 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 109 beds and averages 104.6 residents a day — about 96% 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 3.06 hrs/resident/day on weekends vs 3.54 on weekdays — 14% thinner on weekends. RN hours go from 0.86 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-01-24 · 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 review of facility documentation, review of policy and procedures, review of clinical records, review of hospital records, observation and interviews with staff, it was determined that the facility failed to provide adequate supervision to a resident with a history of over-the-counter medication usage. The facility failed to conduct a thorough assessment of the resident's environment to ensure that the resident was not in possession of over-the-counter medication for one of seven residents reviewed (Resident R31), which resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy, Visitation, revised September 2022, revealed, Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of others in the facility. 1. Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security, and or rights of the facility's residents. Restriction of Individual Visitors 6. If 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.
- Potential for harm · F2026-01-14 · 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 observations, policy and interviews with staff, it was determined that the facility failed to ensure sanitary food handling practices were followed by dietary staff. Findings include:Observations during food preparation and service, conducted on January 11, 2026, at approximately 9:30 a.m. with the Food Service Director (FSD), Employee E13, revealed the following staff were observed not adhering to required personal protective equipment and hygiene practices: Dietary aid, Employee E14, was observed handling ready-to-eat food without wearing gloves.Dietary aid, Employee E15 and Cook, Employee E16 was observed preparing food without a hair net.Dietary aide, Employee E17, was observed wearing a hair net that did not fully cover all hair. Dietary aid, Employee E18, was observed wearing a beard covering that did not fully contain facial hair while engaged in food preparation. Dietary aid, Employee E19 and Employee E20, were observed in the main kitchen area without a hair net. These observations occurred during active food preparation and handling of resident meals. Interview…
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 · Edisputed · IDR2026-01-14 · tag F0574 — patternThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observations, and staff interviews, it was determined that the facility did not ensure posting of required State Survey Agency contact information was readily accessible on two of two nursing floors. (Second-Floor and Third-Floor Nursing Units) Findings Include: Review of facility policy titled, Resident Rights with a revised date of February 2011 states, Policy Statement- Employees shall treat residents with kindness, respect, and dignity. Further review of the policy states, Policy Interpretation and Implementation- 1. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to:.u. voice grievances to the facility, or other agency's that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; v. have the facility respond to his or her grievances; w. examine survey results x. communication with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, medical records, observations, and interviews with residents and staff, it was determined that the facility failed to ensure proper infection prevention and control practices for three of five residents observed (Residents R31, R20, and R95). Specifically, the facility failed to implement Enhanced Barrier Precautions (EBPs) during wound care, medication administration via feeding tube, and personal care, placing residents at risk for transmission of multidrug-resistant organisms (MDROs).Findings include:The facility policy titled Enhanced Barrier Precautions (revised December 2024) states that EBPs are implemented to prevent the transmission of MDROs. EBPs are required for residents who are infected or colonized with CDC-targeted MDROs or who have wounds or indwelling medical devices, including feeding tubes, urinary catheters, central lines, or tracheostomies. The policy requires staff to wear gowns and gloves, in addition to standard precautions, during high-contact…
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 · D2026-01-14 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, and staff interview, it was determined that the facility failed to ensure the resident and the residents representative received a written transfer notice that included all required details for one of three closed records reviewed (Resident R112). Findings include: Review of Resident R112's medical records revealed that on December 11, 2025, the resident was admitted to the hospital following a fall. Although documentation indicated that a notification was provided, continued review failed to reveal that the written notice specified the required elements, including detailed reason for the transfer and required regulatory information, in a manner and language the resident or representative could understand. Interview with the Assistant Director of Nursing, Employee E4, conducted on January 14, 2025, at 12:50 p.m. confirmed that the written notification provided for the transfer did not include required details as outlined by regulation. Continued interview with Employee E4 further confirmed that it is not facility practice to ensure transfer notices…
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 before2026-01-14 · 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 observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to medications found at bedside for one of thirty-three residents reviewed. (Resident R62)Findings Include: Review of facility policy titled, Administer Medications with a date of April 2019 states, Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. Further review of the facility policy revealed, 21. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. Review of Resident R62's record revealed the resident was admitted to the facility on [DATE]. The resident had the following medical diagnosis: Parkinsons Disease (Progressive nervous system disorder affecting movement, characterized by tremors, rigidity, bradykinesia…
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 · D2026-01-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy and resident clinical records, it was determined that the facility failed to ensure timely and effective follow-up of consultant pharmacist medication regimen review (MRR) recommendations for two of four residents reviewed. (resident R 137, and R7) This failure had the potential to result in inappropriate medication use and medication errors.Findings include:Review of the facility policy titled Medication Regimen Reviews, dated July 2025, revealed that a licensed consultant pharmacist reviews each resident's medication regimen upon admission and at least monthly, or more often if clinically indicated. The policy requires identification and resolution of medication errors, irregularities, adverse effects, interactions, inappropriate dosing, and lack of monitoring. The policy further requires non-life-threatening irregularities to be reported in writing to the physician within three business days, physician responses to be documented in the medical record, and medication-related issues to be monitored through quarterly reports and incorporated into…
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 · D2026-01-14 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on review on observations, interviews, review of clinical documentation, and review of facility policy it was determined that the failed did not ensure accurate documentation related to pharmacy reviews for one of 22 residents reviewed. (Resident R75)Review of Resident R75 Consultant Pharmacist MMR Recommendation to Prescriber, dated October 15, 2025, indicated Resident has two order(s) for the following: acetaminophen 500mg and Acetaminophen 325mg for mild pain. Please discontinue duplicate order, if appropriate. If both orders are to be given concurrently, please add the total mg dose to each order. Further review revealed a Physician/ Prescriber response to discontinue 325mg and continue with 500mg for scale 1-4 pain. Review of Resident R75 clinical record revealed a physician order for Acetaminophen 500mg discontinued on December 19, 2025. Further review revealed Acetaminophen 325mg order active. Interview with Employee E2, Director of Nursing, on January 14, 2026 at 12:00pm, confirmed incorrect Acetaminophen dose discontinued.
- Potential for harm · E2025-08-28 · 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 observations, review of facility policies, review of facility grievances, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to administer medications in a timely manner for five of five residents reviewed (Residents R1, R2, R3, R4 and R5). Findings include:Review of facility policy, Guideline for Administration of Medications undated, revealed, This guidance is to assist in the timely administration of medications based on time critical and non-time critical scheduled medications. Non-time critical medications will be scheduled for administration in AM, Afternoon, Evening and HS [bedtime] utilizing extended administration times to accommodate the resident's customary routines. Continued review revealed that medications that are prescribed as daily will be defined as In the Morning with medication administration times from 6:30 a.m. through 11:00 a.m.; In the Afternoon medication administration times are 1:00 p.m. through 5:30 p.m.; Evening medication administration times are 6:30 p.m. through 11:00 p.m.; and Bedtime…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the observation, review of facility policy and procedure, review of manufacturers guidelines, and interviews with staff, it was determined that the facility failed to properly label medications upon opening for ophthalmic solutions found on two of three medications carts observed. (third floor carts one and two) Findings: Review of facility policy titled Medication Labeling and Storage revealed the facility stores all medications and biologicals under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medications storage and preparation areas they clean safe and sanitary manner. Multi dose vials that have been opened or at accessed are dated and discarded within 28 days unless the manufacturer specifies a sure they're longer date for the open vial. Observation of medication pass with Employee Licensed nurse, Employee E5 on January 12, 2024, during med pass, inspection of third floor medication cart one revealed seven boxes of multi-use eye drops without any date written on the box…
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 · D2025-01-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for two of 30 residents reviewed (Resident R215 and R165). Findings Include: Review of Resident R215's clinical record revealed the resident was admitted to the facility on [DATE]. Height and weight measurements dated December 11, 2024, revealed Resident R215 was 6 feet 3 inches tall and weighed 225 pounds. Review of Resident R215's clinical record revealed a nursing note dated December 11, 2024, at 11:49 p.m. that a TELS (an electronic system used to enter, manage, and track maintenance requests) request was placed for a bed extender (increases the length and/or width of existing bed to provide more space and comfort). During an interview on January 12, 2025, at 11:35 a.m. Resident R215 reported that the bed was too small (Resident R215 was too tall for the bed) causing his feet to press against the footboard while lying in bed and subsequently causing…
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 17 citations
- Potential for harm · D2025-01-15 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and review of facility policy, it was determined that the facility failed to ensure that the residents right to privacy was protected for two of 30 residents reviewed. (Resident R Findings include: Review of facility policy titled Confidentiality of Information and Personal Privacy dated October 2017, revealed that the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The facility will strive to protect the resident's privacy regarding his or her accommodations, medical treatment, written communication, personal care, visits, and family group meetings. Observation on the third floor activity room on January 13, 2025 at 10:53, the room included eleven residents and two employees, Registered nurse, Employee E8 was observed evaluating a resident's vital signs. registered nurse Employee E8 was overheard relaying the vital measurements to the resident. 28 Pa. Code 201.18(b)(2) Management
- Potential for harm · D2025-01-15 · tag F0655 — isolatedCreate 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, staff and resident interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative that included initial goals based on admission orders, physician orders, therapy services and social services for one of 22 residents reviewed (Resident R164). Findings include: Review of clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis including progressive neurological condition and cerebrovascular accident (stroke) and Parkinson's disease (progressive disease of the central nervous system). Interview with Resident R164 and with resident's family on January 12, 2025 at 11:25 a.m. stated she was admitted to the facility 9 days ago and she was not sure if she was getting all her medications. Continued interview with Resident R164 and resident's family stated they were not provided a written summary of the baseline care plan 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.
- Potential for harm · D2025-01-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring and administering of medications) to meet the needs of each resident for one of 22 residents reviewed (Resident R34). Findings Include: Review of facility policy Unavailable Medication dated June 2021 revealed in conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. Continued review of facility policy Unavailable Medication revealed in the event that a medication ordered for a residents is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall contact the pharmacy regarding the unavailable medication, attempt to obtain the medication from the facility's automated medication dispensing system, notify the physician of the unavailable medication, report the date of the expected delivery, and obtain new orders. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 the facility failed to provide adaptive equipment for 1 of 18 residents observed during dining on the third-floor dining room. Findings: Policy titled Assistive Devices and Equipment revealed the facility maintains and supervises the use of assisted devices and equipment for residents. Devices and equipment that assist with residents' mobility, safety and independence are provided for residents these may include but are not limited to specialized eating utensils and equipment. Recommendations for the use of devices and equipment are based on comprehensive assessment and documented in the residence care plan. Staff and volunteers are trained to demonstrate competency in the use of devices and equipment prior to assisting or supervising residents. Review of Residents R83's quarterly minimum data set (mds- a federal mandated assessment tool for all residents) dated December 9, 2024. Resident R83 entered the facility June 30 2023 with diagnosis' including…
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 · D2025-01-15 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Director of Nursing Services attended a quarterly Quality Assurance Process Improvement (QAPI) committee meeting for nine of nine QAPI meeting documentations reviewed (February 2024 through October 2024). Findings Include: A review of QAPI committee meeting attendees list for the month of February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, September 2024 and October 2024 revealed that it lacked Director of Nursing as attendee for the meetings. This information was confirmed by the facility Regional Staff during a meeting on January 15, 2025, at 1:13 p.m. Facility documentation provided at the time of the survey did not have evidence that the director of nursing attended the meetings. There was no sign in sheet or meeting minutes information available for July of 2024 that any of the required members attended the meeting. Facility did not provide this information at the time of the survey. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that each resident was offered an influenza immunization for two of seven residents reviewed for immunizations (Resident R34 and R315). Findings Include: Review of Resident R34's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 21, 2024, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Interview on January 14, 2025, at 1:38 p.m. with Resident R34 the resident denied being offered the influenza immunization on admission but admitted being willing to accept the vaccine if suggested by the physician. Review of Resident R34's entire clinical record, including immunization history, revealed no documented evidence the resident was offered the immunization on admission or documentation that the resident either received the influenza immunization or did not receive the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 clinical record, and staff and resident interviews it was determined that the facility failed to provide a sanitary and comfortable environment for two of 30 residents reviewed (Resident R220 and R164). Findings Include: Review of Resident R220's clinical record revealed a physician order dated January 1, 2024, for an antibiotic medication to be administered intravenously (medical technique that administers medications directly into the vein) one time per day. Observations on January 15, 2024, at 11:56 a.m. with Director of Nursing, Employee E2, revealed Resident R220's IV pole (a device that holds a bag of intravenous fluids or medications in place as it is being administered to a patient) was soiled at the base of the pole with what appeared to be old tube feeding formula. Interview with Resident R164 and with resident's family on January12, 2025 at 11:25 a.m. stated she had an over the head light that would not turn off. She stated it was broken when she was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-26 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of clinical records and facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for one of three residents sampled (Residents R1) Findings include: Review of Resident's R1 clinical record it revealed admission date on February 7, 2024, for short term rehabilitation. Resident's R1 funding source was Medicare skilled A services. Conntinued review of the clinical record revealed that Resident R1 was discharge from the facility on March 15, 2024. Then, Resident R1 was readmitted from the local hospital on March 19, 2024 with Medicare Part A benefits. On March 26, 2024, at 12:21 p.m. an interview was held with the Social Worker Director who revealed that Resident R1 was discharged as the Medicare service benefits were exhausted. It was further reported when Medicare funding exhausted therefore, Resident R1 did not receive Notice of Medicare Non-Coverage (NOMNC) cms-10123 the right 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.
- Potential for harm · D2024-01-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, and interviews with staff and residents, it was determined that the facility failed to ensure that one of 34 residents received showers. (Resident R6). Findings Include: Review of undated facility policy Resident Rights revealed federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the residents right to self-determination. Review of Resident R6's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2024, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Further review of the MDS revealed the resident was dependent on staff for shower/bathing. Interview with Resident R6 on January 18, 2024, revealed the resident had only received a bed bath since admission but would prefer to take a shower. Review of Resident R6's nursing [NAME] (electronic documentation system that enables nurses and nurse aides 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.
- Potential for harm · D2024-01-24 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 record, observations, and interviews with staff and residents, it was determined that the facility failed to administer a resident's tube feeding per the physician orders for one of one resident with tube feeding reviewed (Resident R6). Findings Include: Review of undated facility policy Enteral Nutrition revealed adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete and include volume and rate of administration. Review of Resident R6's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2024, revealed the resident was admitted to the facility on [DATE], and received nutrition via tube feeding (also known as enteral nutrition - nutrition is delivered using a flexible tube inserted through the nose, or directly into the stomach or small intestine). Further review of the MDS revealed Resident R6 was…
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 · D2024-01-24 · tag F0835 — failed to run the facility competently — isolatedAdminister 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 to ensure that residents were free from accidents related to self administration of medication. This failure placed Resident R31 at high risk for injury and was identified as an Immediate Jeopardy. Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed: The primary purpose of your position it is to direct the day to day functions of the Center in accordance with current federal, state and local standards, guidelines and regulations that govern nursing Centers to assure that the highest degree of quality care can be provided to our residents at all times. As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Review of job description for the Director of Nursing (DON)…
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 · D2024-01-24 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 documents and resident clinical record and staff and resident interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of one residents reviewed (Resident R49). Findings Include: Review of facility policy Binding Arbitration Agreements dated October 2022, revealed binding arbitration agreements are explained to the resident or their representative in a language form, and manner that they can understand. Review of Resident R49's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 19, 2023, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of senile degeneration of brain (loss of intellectual ability). Further review of the MDS, Section C - Cognitive Patterns (items in this section are intended to determine the resident's attention, orientation, and ability to register and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews with staff and review of facility policies and procedures, it was determined that the facility did not ensure an effective infection control program was maintained related to hand hygiene during wound care for one of one resident observed with wounds. (Resident R96) Findings include: Review of facility policy, Handwashing/Hand Hygiene, revised August 2019, revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves; Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 clinical records, review of facility policy, and staff interviews, it was determined that the facility failed to provide a communication device to maintain optimal communication for two of seven residents reviewed. (Residents R1 and R7) The findings include: The facility policy titled Translation and/or Interpretation Services adopted August 2021, indicated that the facility will ensure that non-English speaking residents will have access to translation and/or interpretation methods. The facility must utilize Interactive Voice Response (IVR) to connect to an interpreter for limited English proficient residents. The facility is to provide communication boards to assist health professionals and resident's wo have English language difficulties or communication difficulties to communicate. A review of clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including spinal stenosis (A condition where spinal column narrows and compresses the spinal…
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 · D2023-11-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview with resident and staff, review of resident records and facility policy, it was determined that the facility failed to ensure care and services was provided with dignity and respect related to one resident's dinning experience of two resident records reviewed (Resident R1). Finding include: Review of the facility's policies title Resident rights not dated stated that employee shall treat all residents with respect and dignity. Review of Resident R1's physician orders revealed the resident was diagnosed with multiple sclerosis (MS a chronic disease of the central nervous system) a quadriplegic (paralysis of all four limbs), dysphagia (difficulty swallowing safety) and was on a regular diet with a minced and moist texture . Review of Resident R1's care plan revealed that the resident was at risk for malnutrition due to MS and quadriplegia and was totally dependent on staff with meals. On November 1, 2023, at 1:00 p.m. observation of lunch served to Resident R1 in the dining room with approximately 20 other residents revealed that Nurse Aide (NA),…
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 · D2023-08-21 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical records review, interview with residents and review of facility policy, it was determined that facility failed to provide timely hygiene care to three out of 14 residents reviewed Resident R1, R2, and R3) Findings include: Review of facility's 'Activities of Daily Living (ADL's)' policy, revised on March 2018, states the following: appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) d. dining (meals and snacks) Review of Resident R1's clinical records revealed diagnosis of cerebral infarction (stroke), morbid obesity, muscle wasting and atrophy, abnormalities of gait and mobility, difficulty in walking, unilateral primary osteoarthritis, glaucoma, chronic kidney disease stage 3, heart failure, high blood pressure. Review of Residents R1's care plan, revised on July 14, 2023, revealed that Resident R1 has bowel…
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 · E2023-08-07 · tag F0919 — failed to provide a working call system — patternMake 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 review of resident grievances, observations of the communication system, reviews of policies and procedures, interviews with residents and staff, it was determined that the facility failed to ensure that adequate equipment was used to effectively allow residents to call for staff assistance through a centralized staff work area. Findings include: A review of the policy titled resident call system, dated September 2022 revealed that the facility was responsible for providing a means to call staff directly for assistance through a communication system that alerts staff at a centralized work station. The policy indicated that the resident call system was to remain functioning at all times. The policy also indicated that if an audible communication was used; it would be at a volume level so that it can be easily heard by staff. The policy indicated that if a visual communication was used that the lights remained functional. The maintenance department was responsible for testing the system routinely 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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
$43,154 in federal fines across 1 penalty.
- $43,154 — penalty dated 2024-01-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
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 | Since |
|---|---|---|---|
| CIBC BANK USA | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | since 11/04/2022 |
| PAPADA, JONATHAN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 11/04/2022 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 11/04/2022 |
| HERSH, LEON | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/25/2024 |
| POSEN, MINDEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 11/04/2022 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/20/2025 |
| NUTRACO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/20/2025 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/20/2025 |
| PATEL, HITEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/04/2022 |
| FLAGLER, OSHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 03/13/2025 |
| KAHANOW, AVIVA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 03/13/2025 |
| LEVOVITZ, TZVI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 03/13/2025 |
| ROKEACH, FRAIDE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 03/13/2025 |
| ROKOWSKY, YITZCHOK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 03/13/2025 |
| LOGAN REAL PROPERTY LLC | Organization | ADP OF THE SNF | since 11/04/2022 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | since 11/04/2022 |
| QUINTO NEXGEN LLC | Organization | ADP OF THE SNF | since 11/04/2022 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | since 11/04/2022 |
| SK NEXGEN TR | Organization | ADP OF THE SNF | since 11/04/2022 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | since 11/04/2022 |
| UKR NEXGEN LLC | Organization | ADP OF THE SNF | since 11/04/2022 |
| YK NEXGEN TR | Organization | ADP OF THE SNF | since 11/04/2022 |
| YR NEXGEN TR | Organization | ADP OF THE SNF | since 11/04/2022 |
CMS files one row per role, so the 33 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
13 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.
This home reported $1.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 395662. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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