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Rittenhouse Post Acute

Penn Med Rittenhouse Campus 1800 Lombard St 5th Fl, Philadelphia, PA 19104 · For profit - Limited Liability company · 38 certified beds · (215) 893-2250 Medicare only — no Medicaid

Call the home — (215) 893-2250 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3801 Filbert Street · (215) 662-9485 · Call to confirm hours
Pharmacy
4014 Lancaster Ave · (215) 387-9100 · Call to confirm hours
Grocery
621 N 38th St
Park
3509 Spring Garden St · Typically dawn to dusk
Place of worship
3835 Haverford Ave · (215) 387-6747

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
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 fell from 5 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.2%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine31.8%68.7%79.4%worse
Short-stay residents rehospitalized after admission23.1%22.5%22.6%typical
Short-stay residents with an outpatient ER visit9.5%9.5%12.0%better

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.

66.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 351 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.2%U.S. median 51.5%
Got home and stayed home
8.6%U.S. median 10.7%
Went back to hospital
95.2%U.S. median 56.6%
Met the expected recovery
0.86U.S. median 0.31
Therapy hours / resident / day
0.39hours / resident / day
Physical therapy
0.38hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 95.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 168 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 0.86 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.2%CMS range 63.0–69.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.6%CMS range 6.1–12.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge95.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge92.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge93.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.5%CMS range 3.1–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.531.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.93
RN hours/ resident / day
1.47
LPN hours/ resident / day
2.28
Aide hours/ resident / day
4.68
Total nurse hours/ resident / day
0.57
RN hoursweekends
40.7%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 38 beds and averages 32.5 residents a day — about 86% occupied, or roughly 6 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 4.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 4.18 hrs/resident/day on weekends vs 4.88 on weekdays — 14% thinner on weekends. RN hours go from 1.07 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2025-05-15)
10
at the previous standard inspection (2024-08-29)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2025-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documentation, clinical records, and interviews with staff, it was determined the facility failed to ensure Resident R65 who required supervision/assistance with ambulation was accompanied by an escort during a medical appointment outside of the facility. This failure resulted in actual harm to Resident R65 who sustained a fall and fracture of nasal bone for one of four residents reviewed. (Resident R65) Findings include: Review of facility policy titled Transportation, Diagnostic Services dated December 2008, revealed under section Policy Statement indicated, Our facility will assist residents in arranging transportation to/from diagnostic appointments when necessary. Additional review of facility policy revealed under section Policy Interpretation and Implementation revealed the following: #1. Should it become necessary to transport a resident to a diagnostic service outside the facility, the social service designee or charge nurse shall notify the resident's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a plan of care was related to the diagnosis of seizure for one of two residents reviewed. (Resident R1)Findings include:Review of Resident R1's August 2025 physician orders included the diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); back pain; convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement that can happen during of without seizures) and cerebral infarction (a stroke). Continued review of the resident's physician's orders indicated that the resident also was being prescribed medication for the treatment of seizures (a sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of conscious).Review of the resident's person-centered plan of care did not include a plan of care for the resident's seizure diagnosis to ensure that appropriate goals and interventions are included and in place for this care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure that medication was deliver timely from the pharmacy to be administer to the resident as ordered by the physician for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Policy Services Overview, with a revision date of April 2019 indicated that the facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. The policy also indicated that pharmacy services are available to residents 24 hours a day, seven days a week and indicated that residents will have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.Review of the Resident R1's August 2025 physician orders included a physician's order with a start date of August 10, 2025. at 9:00 a.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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-Coverage (NOMNC) for one of three residents reviewed (Resident R66). Findings include: Review of facility documentation revealed no evidence that the Notification of Medicare Non-coverage was provided to Resident R66. Interview with Director of Social Services, Employee E3 conducted on May 14, 2025, at 11:05 a.m. confirmed that she was responsible for sending the Notice of Medicare Non-Coverage to residents who were discharged from Medication Part A with remaining Medicare days. Continued interview with Social Services, Employee E3 revealed that Resident R66 was scheduled to leave at a planned date of September 27, 2024, but requested to leave on September 25, 2025. Further, Employee E3 also revealed that Resident R66 informed Employee E3 of his wishes to go home earlier a few days before September 25, 2025. Further, Employee E3 also revealed that she informed Rehab about Resident R66 wishing to leave earlier, and that rehab…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility policy, review of clinical records, and staff in our view, it was determined that the facility failed to develop and implement a person center and comprehensive care plan related to resident's nutritional needs and weight loss for one resident. (Resident R1) Findings include: Review of facility policy titled Care Plans, Comprehensive Person Centered dated March 2022, revealed that a comprehensive person center care plan includes measurable objectives and timetables to meet all resident's physical, psychosocial and functional needs. The care plan includes the resident's goals upon admission, reflects currently recognized standards of practice for problem areas and conditions. When possible, the care plan interventions address the underlying source of the problem areas. Assessments of the residents are ongoing, and care plans are reassessed as information about the resident and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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, clinical record reviews and staff interviews, it was determined that the facility failed to monitor, implement and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutrition for two of sixteen resident records reviewed. (Residents R61 and Resident R1) Findings include: Review of facility policy on Weight Assessment and Intervention dated March 2022, section Policy Statement Resident weights are monitored for undesirable or unintended weight loss or gain. Section Policy Interpretation and Implementation Weight Assessment #1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. #2. Weights are recorded in each unit's weight record chart and in the individual's medical record. #3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. #4. Unless…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of residents for two of two residents with diagnosis of PTSD (post-traumatic stress disorder). (Resident R60 and Resident R63) Findings include: Review of facility policy on Trauma Informed Care and Culturally Competent Care dated August 2022 revealed that under section Purpose To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Under section General Guidelines 1. Traumatic events which may affect residents during their lifetime include: a. physical, sexual and emotional abuse; b.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure one resident was free from significant medication error for 1 of 3 resident reviewed. (Resident R1) Findings include: Review a facility policy titled Administering Medications dated April 2019, revealed that all medications are administered in accordance with prescriber orders and residents may self-administer their medication only if the attending physician comment in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the National Institute of Health article titled Magnesium Fact Sheet for health professionals dated June 2, 2022, revealed magnesium is a nutrient that the body needs to stay healthy magnesium is an important for many processes in the body including regulating muscle and nerve function, blood sugar levels, and blood pressure and making protein, bone 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that drugs ad biologicals are stored in a safe/secure environment in accordance with professional standards for one of one medication room and for one of sixteen residents observed. (Resident R60) Findings include: Review of facility policy on Medication Labeling and Storage dated February 2023, under section Policy Statement, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Under section Policy Interpretation and Implementation, subsection Medication Storage 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0801 — isolated
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of personnel files, review of facility documentation, and staff interview, it was determined that the facility failed to employ a qualified registered dietitian. Findings include: Review of dietitian job description revealed the clinical dietitian assesses the nutritional needs and dietary restrictions of the residents to develop and implement a plan of care to meet nutritional needs and maintain overall quality of life. Job descriptions and responsibilities include to complete assessments, chart reviews, develop an individualized nutrition care plan, nutrition focus physical exams, provide nutrition education counseling and support, review all monthly and weekly weights complete assessment and make modifications to nutrition plan of care as clinically indicated. Further review of the dietitians' responsibilities includes collaborate with inner disciplinary team members, consult with positions, assistant coordination of nutritional care services, monitor food service operations, perform all duties necessary and in accordance with the facility policy, understand 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-29 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and a review of employee personnel records, it was determined that the facility's activities program was not directed by a qualified professional as required. Findings included: Interview with the nursing home administrator (NHA) and Regional Staff, Employee E3 on August 26, 2024, at 1:00 p.m., stated Employee E8, Social Worker oversaw facility activity program including programs and assessments and tha the facility did not have any other activity staff. Interview with Employee E8, Social Worker on August 26, 2024, at 2:02 p.m., stated she did not possess a license or registration as qualified therapeutic recreation specialist or an activity professional. She stated she did not have 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program. Employee E8, Social Worker stated she was not a qualified occupational therapist or occupational therapy assistant; or has completed a training course approved by the State. Employee E8, Social Worker confirmed that she did not have…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2024-08-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Facility policy titled Sanitization (revised 2022), indicated that dishwasher machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitation for high temperature dishwasher: wash temperature (150-165 F) and rinse temperature (180 F). During an observation in the main kitchen dish room area revealed a high temperature dishwasher machine with a wash cycle temperature at 172 Fahrenheit (F) and final rinse cycle temperature at 515 F. Follow up kitchen observation revealed wash cycle temperature at 170 F and final rinse cycle temperature at 210 F. Interview with Employee E4, Dietary Director, confirmed the temperatures and stated the facility is in contact with the manufacture to fix the inaccurate readings noted on the digital thermostat. During an observation in the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-29 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 review of facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to establish Enhanced Barrier Precautions for five of six residents reviewed (Resident 62, Resident 63, Resident 65, Resident 112, Resident 116). Findings include: Enhanced Barrier Precautions dated August 2022 revealed that Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: d.…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0623 — isolated
    Provide 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 one records reviewed related to hospital transfers (Residents R10). Findings include: Review of progress notes for Resident R10 revealed a note, dated May 28, 2024. which indicated that the resident was transferred to a local hospital emergency department due her medical conditions. A request for the evidence of notification of the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers were requested to the administrator and facility administrative staff from previous management, Employee E5. Facility did not submit evidence of notification of the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as requested. Interview on August 27, 2024, Employee E5 confirmed that the Office of the State Long-Term Care Ombudsman was not notified as required 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 ensure that a comprehensive assessment was conducted with direct observation and communication with resident as required for one of eight residents reviewed. (Resident R62) Findings Include: Review of RAI (Resident Assessment Instrument) manual Section J, under the tile of Should Pain Assessment Interview Be Conducted? revealed guidelines for pain assessment which indicated Health-related Quality of Life o Most residents who are capable of communicating can answer questions about how they feel. o Obtaining information about pain directly from the resident, sometimes called hearing the resident's voice, is more reliable and accurate than observation alone for identifying pain. Planning for Care o Interview allows the resident's voice to be reflected in the care plan. o Information about pain that comes directly from the resident provides symptom-specific information for individualized care planning. Steps for Assessment 1. Interact with the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the review of clinical records and staff interviews, it was determined that the facility failed to complete comprehensive assessments that accurately reflected the resident status for one of eight residents reviewed (Resident R62). Findings include: Review of MDS (Minimum Data Set-Assessment of Resident needs) Section J dated August 13, 2024 for Resident R62 revealed that a pain assessment was completed. Further review of the MDS revealed that there was an interview conducted with Resident R2 and the following question and resident response were documented. Ask resident: Have you had pain or hurting at any time in the last 5 days? Response was documented as Yes Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Response was documented as Frequently Ask resident: Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? Response was documented as Rarely or not at all Ask resident: Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for one of three residents reviewed (Resident R65, R62 and R64). Findings include: Interview with Resident R65 on August 26, 2024, at 10: 02 a.m. stated she did not receive a copy of the baseline care plan including the initial goals of the resident, a summary of the resident's medications and dietary instructions and services and treatments to be administered by the facility. A review of the clinical record for Resident R65 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record for Resident R65 revealed no evidence that the facility provided written summary of baseline care plan to the resident or the resident representative. Interview with Resident R62 on August 26, 2024, at 10:20 a.m. stated she did not receive 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, interviews with staff and resident, it was determined that the facility failed to provide care and services to a surgical wound according to professional standards of practice and as ordered by the physician for one of eight residents reviewed. (Resident R65) Findings Include: Interview with Resident R65 on August 26, 2024, at 10:00 a.m. stated she was admitted to the facility two weeks ago from the hospital after a back surgery. Resident stated she had surgical incision to her back which was hard for her to monitor and care. Resident stated facility staff did not monitor or cleaned the incision for few days after her admission. Resident stated after few days she had to call the physician and complained to the staff to get the treatment in place. Resident also stated the incision eventually became infected and she was on antibiotics. Review of hospital record for Resident R65 dated August 14, 2024, revealed an order to clean the incision with soap and water daily. Further…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the review of facility documentation, review of clinical records, staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for one of eight residents reviewed. (Resident R64) Findings include: Review of physician order for Resident R64 dated August 18, 2024 revealed orders for the following medications: Amlodipine (treat high blood pressure) Tablet 5MG (milligrams) 1 tablet by mouth one time a day Atorvastatin (treat high cholesterol) Oral Tablet 80 MG 1 tablet by mouth one time a day Ezetimibe (it can lower high cholesterol levels.)Tablet 10 MG by mouth one time a day Repatha(It can lower high cholesterol levels.) Subcutaneous Solution 140 MG/ML subcutaneously one time a day every 14 day(s) Venlafaxine(used to treat depression) ER oral Tablet Extended Release 150 MG by mouth one time a day Metoprolol Tartrate Tablet (treat high blood pressure) 100 MG by mouth two times a day Ramipril (Treat high blood pressure) Oral Capsule 10 MG by mouth two times a day. Review of Medication Administration Record for 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist or their designee attended a quarterly Quality Assurance Process Improvement (QAPI) committee meetings for four of four quarters reviewed (October 2023 through July 2024). Findings Include: A review of QAPI committee meeting attendees list via online web meeting for the month of October 2023, January 2024, April 2024 revealed that it lacked an Infection Preventionist. There was no sign in sheet or QAPI information available for July 2024. Interview with Clinical Administrative staff, Employee E5, on August 28, 2024, at 11:00 a.m. confirmed that there was no Infection Preventionist attended the QAPI meeting for the facility. 28 Pa. Code 201.18 (1)(3) Management.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 comprehensive care plans to meet care needs for two of 11 residents reviewed. (Resident R112) Findings include: Review of facility policy titled, Documentation in the Inpatient Medical Record revised July 19, 2023, indicated that within 24 hours of patient admission, nursing develops a plan of care based on the patient's goals, and individualizes interventions specific to the patient's identified goals. Nurses evaluate the patients plan of care and the patients' progress. The Nursing Care Plan is kept current by ongoing assessments of the patients needs and of the patient's response to interventions or change in condition. Review of Resident R112's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated October 4, 2023, revealed Resident R112 was admitted to the facility on [DATE], with diagnoses including dementia (progressive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure residents were provided food that accommodates resident's allergies for one of 11 residents reviewed. (Resident R66) Findings include: Review of Resident R66's clinical record revealed the resident was admitted to the facility August 22, 2023, and had a diagnosis of anaphylactic reaction due to fish (A serious life-threatening allergic reaction which usually occurs within few seconds or minutes of exposure to allergic substances). Further review of Resident R66's clinical record revealed a progress note by a physician, EmployeeE10, dated September 1, 2023, at 1:48 p.m., which stated, Patient noted by RN to begin coughing after taking a bit of her lunch. I went to patient's room to evaluate her. I noted that patient appeared to be short of breath w/ wheezing and stridor. Pt reports she has a fish allergy and received fish for lunch. I requested epi pen, non available on floor . Decision then made to transfer patient to the ER at PAH for further…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews with staff it was determined that the facility failed to ensure that garbage and refuse was disposed of properly in the Food Service Department's receiving area. A tour of the Food Service Department conducted on October 2, 2023, at 9:30 a.m. with the Food Service Director (FSD), Employee E13 revealed the following: Observation in the receiving area revealed multiple grey trashcans were open and filled with water, algae, water worms, plastic cups, plastics, gloves, and other trash. Other gray colored trashcans were flipped upside down and contained holes throughout. Wooden pallets were stacked unevenly beside the trashcans and receiving entrance area. Interview on October 2, 2023, at approximately 9:45 a.m. with the FSD confirmed the above-mentioned findings and acknowledged that the current receiving, and dumpster area allowed pest harborage (conditions or place where pests can obtain water or food, nest, or obtain shelter). The facility failed to maintain the outside dumpster area in a safe and sanitary condition. 28 Pa. Code 201.18(b)(3)…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0922 — failed to maintain the building's systems — isolated
    Have enough backup water supply for essential areas of the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility Emergency Operations plan, observation, and staff interview, it was determined that the facility failed to establish written procedures to ensure that potable (drinking) water was available to essential areas during periods when there was a loss of normal water supply. Findings include: Review of the facility Emergency operations Plan, revised on July 3, 2023, revealed the facility does not have provisions to obtain the minimum amount of water required in the event of an emergency. Observation of the dry storage room of the main kitchen conducted on October 2, 2023, at 9:51 a.m. revealed there was no emergency drinking water stored onsite. Review of facility documentation revealed an order was placed for Deer Park Water on October 2, 2023, at 10:27 a.m. and had a delivery date of October 4, 2023. Interviewed with the Food Service Director, Employee E13 and the facility Administrator conducted on October 3, 2023, at approximately 11:30 a.m. confirmed that the last water bottle was distributed over the weekend and that the facility was in the process 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation and interviews with staff, it was determined that the facility did not maintain an annual abuse prevention training program, for one out of five personnel files reviewed (Employee E6) Findings include: Review of facility's policy titled 'Abuse, Neglect, Misappropriation of Resident Property', effective March 22nd, 2027, states that All facility employees will be in-serviced at the time of initial orientation, annually, and subsequently as the needs dictate regarding the following: Definitions of resident abuse, neglect, and misappropriation of resident property. Review of nurse aide's personnel file, employee E6, on October 4th, 2023 at 11:30 a.m., revealed that E6 was hired on June 25, 2023. Review of e-mail sent by facility's director of nursing, employee E2, on July 7th, 2023 at 3:46 p.m., revealed the following: We are in our 2023 Annual PA Department of Health Survey window. In addition to knowledge link, there are 5 mandatory education requirements that still must be completed by all staff. Attached are five (5) mandatory education…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 86 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Avalon Rehabilitation And Healthcare CenterHamilton, NJ 1 of 5Bay Harbor Post Acute Healthcare CenterSalisbury, MD 1 of 5Blueberry Hill Rehabilitation And Healthcare CtrBeverly, MA 1 of 5Canterbury Rehabilitation And Healthcare CenterRichmond, VA 1 of 5Cape Cod Post Acute CareBrewster, MA 1 of 5Crest Pointe Rehabilitation And Healthcare CenterPt Pleasant, NJ 1 of 5Highland Park Rehabilitation And Healthcare CenterChelsea, MA 1 of 5Mount Holly Rehabilitation & Healthcare CenterLumberton, NJ 1 of 5Nashua Post Acute CareNashua, NH 2 of 5Arbor Ridge Rehabilitation And Healthcare CenterWayne, NJ 2 of 5Atlantic View Post AcuteNewport News, VA 2 of 5Bayview Rehabilitation and Healthcare CenterNorth Kingstown, RI 2 of 5Collingswood Rehabilitation And Healthcare CenterRockville, MD 2 of 5Elmhurst Rehabilitation and Healthcare CenterProvidence, RI 2 of 5Graduate Post AcutePhiladelphia, PA 2 of 5Heritage Hills Nursing & Rehabilitation CenterSmithfield, RI 2 of 5Laurel Brook Rehabilitation And Healthcare CenterMount Laurel, NJ 2 of 5Lawrence Rehab & Hcc/The Meadows At LawrenceLawrenceville, NJ 2 of 5Lawrence Rehabilitation HospitalLawrenceville, NJ 2 of 5Lighthouse Rehabilitation And Healthcare CenterRevere, MA 2 of 5Lincolnwood Rehabilitation and Healthcare CenterNorth Providence, RI 2 of 5North End Rehabilitation And Healthcare CenterBoston, MA 2 of 5Orchard Hill Rehabilitation And Healthcare CenterTowson, MD 2 of 5Palm Springs Post AcuteChelmsford, MA 2 of 5Riverview Healthcare CommunityCoventry, RI 2 of 5Roosevelt Rehabilitation And Healthcare CenterPhiladelphia, PA 2 of 5Southampton Rehabilitation And Healthcare CenterRichmond, VA 2 of 5Springfield Rehabilitation And Healthcare CenterSpringfield, PA 2 of 5West Chester Rehabilitation And Healthcare CenterWest Chester, PA 2 of 5Westgate Hills Rehab & Healthcare CtrBaltimore, MD 2 of 5Willow Brook Rehabilitation And Healthcare CenterWilmington, MA 2 of 5YORK Post AcuteYorktown, VA 3 of 5Alexandria Rehabilitation And Healthcare CenterAlexandria, VA 3 of 5Aspen Hill Rehabiliation & Healthcare CenterHaverhill, MA 3 of 5Belmont Bay Rehabilitation And Healthcare CenterWoodbridge, VA 3 of 5Brighton Post Acute CareBrighton, MA 3 of 5Cambridge Rehabilitation And Healthcare CenterMoorestown, NJ 3 of 5Capitol Rehabilitation And Healthcare CenterHarrisburg, PA 3 of 5Chelsea Rehabilitation And Healthcare CenterGoochland, VA 3 of 5Exton Post AcuteExton, PA

Showing 40 of 86; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
CIBC BANK USAOrganization5% OR GREATER MORTGAGE INTERESTsince 09/12/2024
HARMAN, DINAIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/12/2024
MCGLONE, DARRELLIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/12/2024
PAPADA, JONATHANIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/12/2024
VIROJA, YOGESHIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/12/2024
POSEN, MINDEEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 05/01/2024
MARQUIS LIMITED LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/12/2024
NUTRACO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/12/2024
RELIANT PRO REHAB, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/12/2024
KIRCHDOERFFER, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/12/2024
FLAGLER, OSHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/20/2025
LEVOVITZ, TZVIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/20/2025
ROKOWSKY, YITZCHOKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/20/2025
CEDARBRIDGE FINANCIAL SERVICES LLCOrganizationADP OF THE SNFsince 09/12/2024
MARQUIS HEALTH CONSULTING SERVICES LLCOrganizationADP OF THE SNFsince 09/12/2024
QUINTO NEXGEN LLCOrganizationADP OF THE SNFsince 05/01/2024
TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIAOrganizationADP OF THE SNFsince 09/12/2024
ZIMMET HEALTHCARE SERVICES GROUP LLCOrganizationADP OF THE SNFsince 09/12/2024

CMS files one row per role, so the 29 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

9 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.

What families pay in PA

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Pennsylvania Medicaid page for homes that do.

Typical monthly cost in Pennsylvania
$11,954/mo
Nursing home (semi-private)
$13,688/mo
Nursing home (private)
$6,480/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395749. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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