Oakwood Healthcare & Rehabilitation Center
2109 Red Lion Road, Philadelphia, PA 19115 · For profit - Corporation · 148 certified beds · (215) 673-7000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $5,269 in federal fines (most recent 2024-02-12)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 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 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.2% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.5% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 52.4% | 10.8% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.5% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.8% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.0% | 25.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.6% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.9% | 68.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.8% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.0% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.04 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.72 | 1.18 | 1.80 | typical |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ 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.
39.2% 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 165 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.4% 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 106 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 39.2%CMS range 31.2–48.0 | 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 | 11.9%CMS range 8.6–15.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 59.4% | 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 | 54.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.5% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.8% | 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 | 1.1% | 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 | 2.8% | 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 | 9.9%CMS range 6.7–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 148 beds and averages 134.8 residents a day — about 91% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above 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 3.67 hrs/resident/day on weekends vs 4.19 on weekdays — 12% thinner on weekends. RN hours go from 0.59 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 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
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.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · E2026-05-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of food safety standards, observations, and staff interview it was determined that the facility failed to ensure beverages were stored in accordance with standards for food service safety.Findings Include: Review of Refrigeration & Food Safety guidelines by the United States Department of Agriculture (USDA), Food Safety and Inspection Service, revealed cold food should be kept at or below 40 degrees Fahrenheit (F). Further review of guidelines by the USDA revealed the danger zone is defined as temperatures between 40 and 140 degrees F where bacteria grow most rapidly. A tour of the main kitchen conducted on May 4, 2026, at 9:30 a.m. with the Food Service Director, Employee E11, and District Manager, Employee E12, revealed the following: Observations of the milk cooler revealed the gasket (a sealing component used to keep the milk at correct temperatures by maintaining an airtight seal between the cooler's body and its lid) was broken and needed to be replaced. Observations inside the milk cooler revealed it was fully stocked with a fresh delivery of individual milk…
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 before2026-05-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of two sampled residents (Residents R2).Findings include:A review of Resident R2's clinical record revealed an admission date of January 23, 2026, with diagnoses including chronic respiratory failure with hypoxia, epilepsy, tracheostomy (surgically created opening in the neck into trachea to assist with breathing), dysphagia (difficulty swallowing). A physician's order dated January 23, 2026, revealed, Administer oxygen at 5 liters per min via trach continuously. A comprehensive care plan, last revised on January 26, 2026, revealed, oxygen as ordered via trach mask. On May 4, 2026, at 11:24 a.m., an observation was conducted with Licensed Nurse, Employee E3, who confirmed that Resident R2's oxygen was set at 1.5 liters, which was inconsistent with the physician's order. On May 5, 2026, at 2:0 p.m., an observation was conducted with the Unit Manager, Employee E4, who confirmed that 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 · D2026-05-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to ensure medications were stored according to required temperature ranges and failed to maintain refrigeration equipment in a sanitary and operational condition.Findings Included: Review of Medication Room Temperature Log states, temperature are to remain between 36-41 degrees. Defrost freezer monthly on the fifteenth. Observation conducted on May 4, 2026, at 10:30 am, with Nurse Manager, Employee E4 of Medication Room Refrigerator revealed two out of three days the refrigerator temperature exceeded the acceptable range of 36-41 degrees. The facility failed to notify maintenance of the temperature variance and failed to remove or quarantine medications exposed to out of range temperatures. On Monday May 4, 2026, at 10:30 am, with Nurse Manager, Employee E4 observation of Medication Room Refrigerator revealed approximately five inches of ice accumulation in the freezer compartment. The facility failed to notify maintenance of excessive ice buildup and failed to defrost the refrigerator. 28 Pa. Code 201.18(b)(1) Management
- Potential for harm · Dcited before2026-05-07 · 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 a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement Enhanced Barrier Precautions for one of two residents reviewed who had a tracheostomy, feeding tube, and an indwelling urinary Foley catheter (Resident R2).Findings include:Review of facility policy and procedure titled Enhanced Barrier Precaution (EBP) revealed All applicable employee to adhere to Enhanced Barrier Precautions, per guidelines. Under Process: A physician order for enhanced barrier precautions is entered in the EHR. The order will contain the a reason for the EBP. EBP will be Care Planned and tasked out to the Care Kardex. An Enhanced Barrier Precautions sign will be posted on the door/outside of the room, of Residents that required Enhanced Barrier Precautions. A red Dot (Sticker) will be placed on the affected Resident's door tag to indicate which Resident requires Enhanced Barrier Precautions. The Unit Manger is responsible for: Updating and completion of the Enhanced Barrier Precautions log, Providing the IP or designee an updated EBP…
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 · D2025-06-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for two of 26 residents reviewed. (Resident R24, R433) Findings Include: A review of the facility policy titled Oakwood Health and Rehabilitation Center Policy and Procedure, revised September 2023, revealed the following under Section #6, Investigating and Reporting: Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator of Nursing immediately and initiate gathering the requested information. An investigation must be directed by the Administrator or designee immediately. Review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of muscle wasting and atrophy, heart failure, need for assistance with personal care, other abnormalities of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to fall interventions for one of three records reviewed for falls. (Resident R5). Findings include: Review of facility policy, Care Plans, Comprehensive Person Centered, revised March 2022, indicated that care plans are revised as information about the resident's change. Review of clinical documentation revealed that Resident R5 was readmitted to the facility on [DATE], had diagnoses including, but not limited to, muscle wasting, difficulty walking and atrophy, and muscle weakness. Review of Progress Note dated, October 15, 2024, revealed Resident R5 had an unwitnessed fall and was observed sitting on the floor next to her bed. Further review revealed that on October 16, 2024, Resident R5 complained of right femur pain post fall yesterday. On October 17, 2024, Resident R5 was admitted to the hospital with diagnosis of right femur fracture. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-05 · 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 a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for five of the five residents reviewed (Residents R24, R53, R33, R93, R433) Findings: Review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of muscle wasting and atrophy, heart failure, need for assistance with personal care, other abnormalities of gait and mobility, disorder of muscle, adult failure to thrive, difficulty in walking, muscle weakness. A review of Resident R24's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14, reflecting cognitive intact. The functional abilities section of the MDS indicated that Resident R24 requires partial/moderate assistance with toileting hygiene tasks. An interview conducted on June 2, 2025, at 12:35 p.m.…
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 · D2025-06-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record reviews and interviews with staff, it was determined that the facility failed to follow the physician orders related to medication administration for one of 26 residents reviewed (Residents R433). Findings include: Review of Resident 433's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of adult failure to thrive, muscle wasting and atrophy, acquired absence of left leg above knee, and muscle spasm. A review of Resident R433's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15, reflecting cognitive intact. A review of the clinical progress notes indicated a progress physician note dated on May 16, 2025 indicated resident admitted to the facility. She is alert and oriented. All medication were reviewd and verified with physician, [Employee E3]. Review of hospital's physician orders indicated that Resident R433 was prescribed Insulin Aspart Flex Pen 100 unit/ml Sopn…
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 · D2025-06-05 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to implement non-pharmacological interventions in accordance with professional standards for one of 26 residents reviewed (Resident R120). Findings include: Review of facility policy Pain Evaluation and Management Policy, revised December 12, 2020, revealed that The comprehensive pain evaluation is reviewed by the nurse and the physician, and interventions are implemented as appropriate. Care plans will be developed to include both pharmacologic and non- pharmacologic interventions. Care plans will be reviewed and revised as new interventions are needed. Review of Resident R120's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses including fracture of left femur(left hip fracture) with orthopedic aftercare. Review of Resident R120's care plan revised May 2, 2025, revealed the resident was at risk for pain related to the diagnosis of left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · 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 review of facility policy and procedures, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to the use of appropriate personal protective equipment for one of three nursing units on transmission-based isolation precautions. (B unit) Findings include: Review of a undated facility policy titled Managing Residents with COVID-19, revealed 1. Use of standard and transmission-based precautions for COVID-19, per current guidelines, with appropriate PPE use and signage. 2. Place in a single-person room when able. 3. If single-room quarantine is unavailable due to limited single rooms or multiple residents are identified as COVID-19 positive, resident~ positive for COVID-19 will be cohorted. 5. Restrict the resident to their room when[ possible. 6. Provide the resident with a surgical mask if they need to leave their room. 7. Restrict residents to medically necessary outings during the isolation period Review of CDC guidelines for COVID-19 revealed that Residents placed in Transmission-Based…
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 12 citations
- Potential for harm · D2025-03-10 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure complete and accurate medication administration for one of 9 residents reviewed (Resident CR1). Findings include: The Facility Policy titled Administering Medication revised on [DATE], revealed Mediations are administered in a safe and timely manner, and as prescribed. It further under policy interpretation and implementation 23. states As required or indicated for a medication, the individual administering the medication records in the resident's medication record. A. the date and time the medication was administered, b. the dosage, c. the route of administration, d. the injection site (if applicable), e. any complaint or symptoms for which the drug was administered, f. any results achieved and when those results were observed, and g. the signature and title of the person administering the drug. Clinical record review revealed the facility admitted Resident CR1 on [DATE], and expired on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-29 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of staffing schedules, facility documentation, and staff interview, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 26 residents reviewed (Residents R78, R100, R32). Findings include: A review of the clinical record revealed Resident 78 was admitted to the facility on [DATE]. Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 222, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 14-cognition intact On August 26, 2024, at 10:40 a.m., an interview was conducted with Resident R78, who expressed feeling very upset and began crying. Resident R78 stated, They don't answer the call bell and make me wait for an hour to be changed. The last time I was changed was at 6:00 a.m. this morning. The surveyor asked her to press the call bell, but it was not functioning, as the indicator light did not…
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 · D2024-08-29 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units (Unit A Medication Cart). Findings include: During an observation on August 26, 2024, at 12:50 p.m. the Infection Preventionist, Employee E3 confirmed Medication Cart that was assigned to license nurse, Employee E5 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E3 was not in the hallway nor near her medication cart. During an observation on August 26, 2024, at 2:25 p.m. the license wound nurse, Employee E8 confirmed Medication Cart that was assigned to license nurse, Employee E5 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E5 was not in the hallway nor near her medication cart. On August 29, 2024, at 11:44 a.m. an Administrator, Employee E1…
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 · D2024-08-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 record, review of policy and procedure, and interviews with staff and residents, it was determined that the facility failed to investigate an allegation of possible abuse and neglect and report to the State survey agency the result of the investigation for one of 26 clinical records reviewed. (Resident R44) Findings include: Review of Resident R44's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of schizophrenia (mental disease characterized by loss of reality contact), major depression, muscle spasticity, low back pain with sciatica (pain going from the lower back down the leg), IV (intravenous) drug abuse. Review of Resident R44's February 2024 physician orders revealed that the resident was ordered May 3, 2023, the pain/ narcotic medication Oxycodone 5 milligrams (mg) by mouth five times a day for severe pain and on May 5, 2023 Baclofen 10 mg by mouth ever six hours as needed for muscle spasms. Clinical record review revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans related to elopement for one out of 26 residents sampled (Resident 78). Findings include: A review of the clinical record revealed Resident 78 was admitted to the facility on [DATE], with diagnoses of depression, anxiety disorder, recurrent, borderline personality disorder, narcissistic personality disorder. A review of a physician order, initially dated August 21, 2024 revealed the resident had a wanderguard (device that is place on ankle or wrist that activate the locking mechanism on doors to the outside of the facility) to back/right armrest of W/C (wheelchair). A review of progress notes dated, August 21, 2024, written by the license nurse, Employee E16 revealed resident continuously refused to take her meds. Resident has an increase aggression physically and verbally to staff. Resident was screaming/yelling/swinging at staff. Resident is at risk for elopement, stated I'm going…
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 · D2024-08-29 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing and vision abilities for one of 26 residents reviewed (Resident R32). Findings include: Review of the clinical record indicated that Resident R32 was admitted to the facility on [DATE], with diagnoses to include anxiety disorder, major depressive disorder, rheumatoid arthritis (chronic autoimmune disorder which effects joints, causing inflammation, pain and swelling), osteoporosis (bones loose density, making them thinner and less durable). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R32, dated, July 18, 2024 revealed that the resident was cognitively intact. Review of Resident R32's inhouse new Audiology summary dated January 25, 2024, indicated a recommendation for the Resident R32 for in office visit for myringotomy treatment (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 · D2024-08-29 · 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 policy, facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to appropriately determine the effectiveness of interventions for a resident who was assessed as an elopement risk for one of the 26 residents reviewed (Resident R78) Findings include: A review of the facility policy titled Elopement Risk Evaluation Policy revised 12/12 revealed It is the policy of the facility that all residents will be evaluated upon admission, re-admission quarterly and with any changed in the resident's status to assess their risk for elopement. The Elopement Risk Evaluation will be reviewed and completed. Under procedure number 4. Interventions will be developed and implemented by the interdisciplinary Care Plan Team. The Interdisciplinary Team will re-evaluate interventions with each Elopement Risk Evaluation care conference and with any change in the resident's status. A review of the clinical record revealed Resident 78 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 · Dcited before2024-08-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate tracheostomy care for one of 26 residents (Resident R71). Findings include: Review of the clinical record indicated that Resident R71 was admitted to the facility on [DATE], with a diagnosis of encounter for attention to tracheostomy (a surgically created opening in the neck that allows direct access to the trache for breathing), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), acute respiratory failure hypoxia (is an emergency where the lungs are unable to supply enough oxygen to the blood, leading to dangerously low oxygen level (hypoxia). A review of Resident R71's Quarterly Minimum Data Set (MDS), a periodic assessment of care needs, dated July 21, 2024, showed that the Brief Interview for Mental Status (BIMS), which assesses cognitive function, returned a score of unknown, indicating that 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 · D2024-08-29 · 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 review of facility provided documentation, and review of clinical record, it was determined that the facility did not ensure to have attending physician address and document pharmacist's identified irregularities for one of 26 residents reviewed (Resident R127) Findings include: Review of facility provided policy 'Pharmacy Consultant Recommendations,' revised December 16 (unknown year), indicates that the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Review of R127's clinical record on August 29, 2024 at 12:00 PM, revealed Resident R127 was admitted to facility July 26, 2024 with BIMS (Brief Interview of Mental Status) score of 5, which indicated that the resident was cognitively impaired. The resident's diagnoses included of depression, subsequent encounter of falls, muscle wasting and atrophy, dementia with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to establish Enhanced Barrier Precautions for three of 26 residents observed (Resident 71, Resident 4, and Resident 63) Findings include: Review of facility policy and procedure titled Enhanced Barrier Precaution (EBP) revealed All applicable employee to adhere to Enhanced Barrier Precautions, per guidelines. Under Process: A physician order for enhanced barrier precautions is entered in the EHR. The order will contain the a reason for the EBP. EBP will be Care Planned and tasked out to the Care [NAME]. An Enhanced Barrier Precautions sign will be posted on the door/outside of the room, of Residents that required Enhanced Barrier Precautions. A red Dot (Sticker) will be placed on the affected Resident's door tag to indicate which Resident requires Enhanced Barrier Precautions. The Unit Manger is responsible for: Updating and completion of the Enhanced Barrier Precautions log,…
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 · E2024-05-30 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that the resident had the right to choose healthcare and providers of healthcare consistent with resident's interests and plan of care for one of three residents reviewed. (Resident R1) Findings Include: Interview with Resident R1 on May 30, 2024, at 10:00 a.m. stated he did not want Employee E4, Licensed Nurse, to provide care for him. He stated after the last survey by the State Survey Agency in September 2023, he did not want her to provide him care and administer medications. Resident also stated she made mistakes with his medication administration, and he was told by the facility staff that Employee E3 would not administer him his medications. Resident R1 stated Employee E4 prepared and administered his medications numerous times even after he requested not to have Employee E4 as his nurse. Interview with Employee E3, Unit Manager on May 30, 2024, at 10:00 a.m. stated Licesed nurse, Employee E4 should not administer medication to Resident R1. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-08-29 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and an interview with staff, it was determined that the facility failed to ensure that the Department of Health Survey results were readily accessible to residents and visitors on three of three nursing units. (A, B, C nursing units) Findings Include: On August 27, 2024, at 10:36 a.m. a resident group meeting was held with nine alert and oriented residents ( R75. R115, R83, R83, 51, R55, R34, R4, R99, R48) who reported that they were not aware of the survey results binder and were not aware of the location where the survey results binder would be located and available to review. Observation on August 27, 2024, at 11:27 a.m. revealed the survey binder was in the main lobby behind the receptionist desk. Further observation with the Nursing Home Administrator, Employee E1 revealed the survey binder on nursing units A, B, C were all behind the nursing station desk which confirmed that residents do not have access and it is not readily accessible to residents. Interview on August 27, 2024, at 11:27 with Nursing Home Administrator, Employee E1 confirmed the state…
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.
- 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
$5,269 in federal fines across 2 penalties.
- $1,882 — penalty dated 2024-02-12
- $3,387 — penalty dated 2024-01-22
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 COLEV GESTETNER — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.6 | -0.6 vs chain |
| Health inspection | 4 of 5 | 3.9 | +0.1 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 4.4 | -1.4 vs chain |
The other 6 homes this chain runs (chain average 4.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OAKWOOD SENIOR HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 01/01/2014 |
| GESTETNER, COLEV | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 50% | since 01/01/2014 |
| GROSSMAN, ELIEZER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 01/01/2014 |
| SMITH, SAMUEL | Individual | CORPORATE DIRECTOR | — | since 05/30/2018 |
CMS files one row per role, so the 7 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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395110. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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.