Paul's Run
9896 Bustleton Avenue, Philadelphia, PA 19115 · Non profit - Corporation · 119 certified beds · (215) 934-3000 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 4 to 5 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 | 16.6% | 16.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.3% | 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 | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.5% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.1% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.8% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.4% | 20.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 30.8% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.6% | 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 | 60.6% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.8% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.3% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.02 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.64 | 1.18 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
65.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 420 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 80.9% 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 220 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 65.7%CMS range 61.4–70.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.8–13.6 | 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 | 80.9% | 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 | 75.5% | 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 | 75.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.4% | 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 | 1.9% | 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 | 7.1%CMS range 4.8–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.74 | 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 119 beds and averages 113.8 residents a day — about 96% occupied, or roughly 5 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 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.67 hrs/resident/day on weekends vs 3.97 on weekdays — 8% thinner on weekends. RN hours go from 0.66 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below 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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · Dcited before2025-08-29 · 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 clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to report a resident's fall incident and bruise to the local State agency as required for one of four residents reviewed for falls (Resident R14).Findings include:Review of facility policy Investigating Incident Reports and Adverse Events, not dated, revealed all adverse events occurring to residents will be investigated for root cause and to rule out abuse and neglect. An adverse event includes falls, both witnessed and unwitnessed.Clinical record review revealed Resident R14 was admitted to the facility on [DATE] with a diagnosis that included Cerebrovascular Accident (known as stroke, disruption of blood flow to brain, which can lead to brain damage), hemiplegia and hemiparesis affecting right dominant side (affect movement/sensation on one side of body). Review of Resident R14's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs)…
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 · D2025-08-29 · 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 clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided during transfer for one resident which resulted in a fall incident for one of three residents reviewed for falls (Resident R14).Findings include:Review of facility policy Fall Prevention Protocol, not dated, revealed each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Clinical record review revealed Resident R14 was admitted to the facility on [DATE] with a diagnosis that included Cerebrovascular Accident (known as stroke, disruption of blood flow to brain, which can lead to brain damage), hemiplegia and hemiparesis affecting right dominant side (affect movement/sensation on one side of body). Review of Resident R14's Minimum Data Set (MDS)…
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 before2025-08-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 policy, and interviews with staff, it was determined that the facility failed to ensure the resident was assessed after a significant weight loss for one of three residents reviewed for weight loss (Resident R75). Review of facility policy Recording the Weight of Each Resident, dated 2024, revealed if the resident's weight has 5% or greater change from the previous month the nursing staff is responsible to re-weigh the resident within 48 hours. If after the re-weight is completed, the resident shows a 5% weight gain or loss, the dietitian will notify the IDT and complete proper documentation. The nursing staff or designee will alert the appropriate individuals of significant changes. Clinical record review revealed Resident R75 was admitted to the facility on [DATE] with a diagnosis that included congestive heart failure (CHF-affects your heart's ability to pump blood), malnutrition (diet does not provide enough nutrients or the right balance for optimal health) 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 · Ecited before2024-10-18 · 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 observations, review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to implement enhanced barrier precautions for eight of eight residents reviewed (Resident R16, R48, R82, R88, R416, R4, R1 ) Findings Include: Review of facility policy dated November 2023 Enhanced Barrier Precautions revealed it is the policy of the facility to use enhanced barrier precautions with residents who are at risk for acquisition and colonization of multidrug resistant organisms (MDRO's). The use of Enhanced Barrier Precautions is indicated during high contact resident care activities for residents with chronic wounds and/or indwelling devices regardless of MDRO colonization. A review of Resident R16's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of neuromuscular dysfunction of the bladder (neurogenic bladder, the relationship between the nervous system and bladder function is disrupted by injury or disease).…
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 · D2024-10-18 · 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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included the information necessary to properly care for a resident within 48 hours of admission for two of 24 residents reviewed. (Resident R69) Findings include: Facility policy titled Baseline Care Plan (2024), indicated that This facility will develop an initial person-centered care plan within the first forty-eight (48) hours of admission for every resident. The Baseline Care Plan will provide instructions for care of the resident. Completion and implementation of the Baseline Care Plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among all facility staff members, increase resident safety and safeguard against adverse events that are most likely to occur in the immediate days after admission prior to development of the Comprehensive Care Plan and to ensure the resident and representative are…
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 before2024-10-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 staff interview, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's needs for one of two residents reviewed for nutrition (Resident R52). Findings Include: Review of facility policy dated January 16, 2024, Recording The Weight of Each Resident revealed if a resident shows a 5% weight gain or loss, the Dietitian should be notified. Any resident with a significant weight loss should be included on the 24 hour report for that day. Review of Resident R52's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 13, 2024, revealed Resident R52 had moderate cognitive impairment and had diagnoses of weakness and Cerebral Vascular Accident. Observation of Resident R52 on October 15, 2024, at 11:05 a.m. revealed Resident R52 had bilateral hand tremors. Interview with Resident R52 on October 15, 2024, at 11:05 a.m. 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 · D2024-10-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, review of clinical records, review of facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for two of five residents reviewed for monthly medication review. (Resident R6 and R34). Findings Include: Review of the policy Medication Regimen Review dated June 28, 2019, revealed that the consultant pharmacist performs a comprehensive medication regimen review at least monthly. Findings and recommendations are reported to the Director of Nursing and Attending Physician. Recommendations are acted upon and documented by the facility staff and/or prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident R6's medical record revealed that resident was admitted on [DATE], with diagnoses including dementia (general term for a decline in cognitive function). A review of the consultant pharmacist report for Resident R6 on July 21, 2024,…
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 before2024-01-02 · 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
Based on review of policies, information provided by the facility, and clinical records review, and staff interviews, it was determined that the facility failed to ensure that staff report an alleged violation involving an injury of unknown origin within the required timeframe for one of 27 residents reviewed (Resident 21). Findings include: A nursing note for Resident 21, dated December 7, 2023, revealed that the resident was observed by the nursing assistant with bluish discoloration above left eyebrow ridge. It measured 1.5 centimeter (cm) x 2.5 cm, and the area was slightly elevated. Review of facility investigation dated December 7, 2023, at 4:30 p.m., revealed that the nursing assistant reported bruise to left eyebrow ridge measured 1. 5cm x 2. 5cm. The bruise was dark purple in color. Resident stated he was punched in the face by the person that took me to the get my hair cut. Further review of investigation revealed a statement by Licensed Practical Nurse (LPN), Employee E14, indicated she observe the bruise before lunch time when she was assisting nurse aide, Employee E15,…
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 · D2024-01-02 · 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 review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included continuous oxygen administration for one of 33 residents reviewed (R41) Findings include: Review of Resident R41's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses that included Heart Failure (a condition that develops when the heart doesn't pump enough blood for the body's needs. This can happen if the heart can't fill up with enough blood. It can also happen when the heart is too weak to pump properly), Atrial Fibrillation (an irregular and often very rapid heart rhythm; it can lead to blood clots in the heart, increases the risk of stroke, heart failure and other heart-related complications), Acute Kidney Failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days, it causes a build-up of waste products in the blood 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 · D2024-01-02 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and clinical records review, it was determined that the facility failed to ensure that that physician orders were followed related to urinary catheter size for one of one residents reviewed with a urinary catheter. (Resident R42) Findings include: Review of Resident R42's clinical record revealed that Resident R42 was admitted to the facility on [DATE] with the diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment; symptoms include forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety Disorder and Malignant Neoplasm of Right Female Breast (The term malignant means the tumor is cancerous and is likely to spread (metastasize) beyond its point of origin). Review of physician order dated December 1, 2023, for Resident R42, indicated an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2024-01-02 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater. Findings include: The facility incurred a medication error rate of 6.25%. Review of R34's physician order revealed an order dated November 1, 2021, to administer Amlodipine Besylate 5 milligrams, give one tablet orally in the morning, for hypertension; hold for systolic blood pressure (SBP) less than 100. (Systolic Blood Pressure indicates how much pressure the blood is exerting against the artery walls when the heart contracts). (Hypertension is high blood pressure; if an individual has high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood). On December 28, 2023, at 9:38 a.m., observed that Employee E13, a Licensed Nurse, administered Amlodipine Besylate 5 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at 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 · D2024-01-02 · 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
Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete one of 30 residents reviewed (Resident R77). Findings Include: Review of Resident R77's dietary progress note dated December 28, 2023, revealed that the resident was trending weight loss for past several months. The dietician was monitoring weekly weights, labs, meal intake and tolerance. Review of Resident R77's November 2023 meal intake documentation revealed that on 19 days only one meal intake was documented. December 2023's meal intake documentation revealed that for 12 days only one meal was documented. Continued review of December 2023's meal intake documentation on December 5, 9 and 15, 2023 only two meals were documented. Interview with the Registered Dietician on January 2, 2023, at 12:00 p.m. stated the resident was not on weekly weight when the dietician completed the documentation on December 28, 2023. Dietician also confirmed that the meal intake documentation was not consistently completed for…
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 before2024-01-02 · 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, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of two nursing units (second floor). Findings include: A review of the facility documentation dated December 28, 2023, revealed 8 residents were residing in the designated COVID-19 rooms on the second floor. Interview with the Nursing Home Administrator and Director of Nursing on December 27, 2023, at 9:30 a.m. revealed that the facility was having a COVID outbreak, 8 residents are located on the second floor. The required Protective Personal Equipment (PPE) for the COVID rooms as required by facilities policy Transmission-Based Isolation Precautions that PPE to be donned upon entrance to the resident room includes goggle or face shield, facemask N95, disposable gowns, and gloves. PPE will be doffed prior to exit of the room and discarded in isolation bins placed inside of resident's doorway . Every staff, and/or visitor…
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 · B2024-10-18 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for one of two records reviewed for hospitalizations (Residents R111). Findings include: Review of progress notes for Resident R111 revealed a note, dated July 20, 2024, at 3:48 p.m., which indicated that the resident had abdominal pain, nausea, and vomiting and was subsequently transferred to a local hospital emergency department for evaluation. Further review revealed that there was no indication that the Office of the State Long-Term Care Ombudsman was notified of Resident R111's facility-initiated emergency transfer to the hospital. Interview on October 18, 2024, at 1:25 p.m. with Social Services, Employee E10, confirmed that the Office of the State Long-Term Care Ombudsman was not notified of Resident R111's facility-initiated emergency transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code…
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 · C2024-01-02 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies and staff interviews, it was determined that the facility failed to ensure that the designated Infection Preventionist completed specialized training in infection prevention and control. Findings include: Review of facility infection control practice documentations revealed no evidence that the facility employed an Infection Preventionist who completed specialized training in infection prevention and control. A request for a copy of the approved Infection Preventionist specialized training in infection prevention and control certification was made to the nursing home administrator, Employee E1, and Director of Nursing, Employee E2, on December 27, 2023, at 10:42 a.m. Facility Nursing Home Administration did not provide the documentation that the facility employed an Infection Preventionist who completed Infection Preventionist completed specialized training in infection prevention and control. Interview with the Director of Nursing, Employee E2 on January 2, 2024, at 12:08 p.m. confirmed that the Director of Nursing assumed the duties of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LIBERTY LUTHERAN SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2001 |
| BORTZ, BEVERLY | Individual | CORPORATE DIRECTOR | — | since 09/01/2012 |
| BRECKENRIDGE, LINDA | Individual | CORPORATE DIRECTOR | — | since 09/01/2019 |
| FERNANDEZ-MILLER, ANNABELLE | Individual | CORPORATE DIRECTOR | — | since 07/01/2024 |
| HIMLER, JAMES | Individual | CORPORATE DIRECTOR | — | since 09/01/2016 |
| MATTHIAS-LONG, WAYNE | Individual | CORPORATE DIRECTOR | — | since 09/01/2021 |
| ROTH, FRANK | Individual | CORPORATE DIRECTOR | — | since 07/09/2025 |
| STEITZ, PAMELA | Individual | CORPORATE DIRECTOR | — | since 09/01/2021 |
| STETTLER, DAVE | Individual | CORPORATE DIRECTOR | — | since 11/01/2016 |
| BARNUM, JOHN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/10/2006 |
| FISHER, LUANNE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/02/1977 |
| MYERS, JOAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 02/09/1987 |
| BEECH III, FRANK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/02/2025 |
| GALANTE, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/13/2007 |
| GRIFFIES-EDWARDS, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2024 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| BANK OF AMERICA CORP | Organization | ADP OF THE SNF | — | since 08/16/2006 |
| CURANA HEALTH OF PENNSYLVANIA PC | Organization | ADP OF THE SNF | — | since 02/15/2024 |
| INTELYCARE INC | Organization | ADP OF THE SNF | — | since 12/21/2022 |
| KREISHER MILLER | Organization | ADP OF THE SNF | — | since 03/31/2025 |
| LOYAL ASSISTANT, INC. | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| MORGAN STANLEY | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| POWERBACK REHABILITATION LLC | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| RKL LLP | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| TWOMAGNETS LLC | Organization | ADP OF THE SNF | — | since 07/01/2024 |
| PATEL, AKULKUMAR | Individual | ADP OF THE SNF | — | since 02/15/2024 |
CMS files one row per role, so the 34 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
11 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 $3.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
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 395738. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.