West Park Rehabilitation And Nursing Center
4401 Haverford Avenue, Philadelphia, PA 19104 · For profit - Limited Liability company · 200 certified beds · (215) 349-8800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- it has 1 actual-harm citation
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $25,847 in federal fines (most recent 2024-09-30)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (70%) runs well above the national median (45%)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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
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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.2% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.0% | 6.2% | 5.4% | typical |
| 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 | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 69.5% | 10.8% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.1% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.0% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.9% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 18.8% | 25.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 31.1% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.1% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.6% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.82 | 1.18 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.0% 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 62 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 40.6%CMS range 27.6–51.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.8–15.4 | 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 | 79.0% | 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 | 80.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.7%CMS range 5.2–14.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 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 200 beds and averages 177.4 residents a day — about 89% occupied, or roughly 23 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 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.550 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.60 hrs/resident/day on weekends vs 4.38 on weekdays — 18% thinner on weekends. RN hours go from 0.66 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 70% is well above 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.
34 citations, most serious first. The 13 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2026-01-08 · 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 staff interviews, review of clinical records, facility documentation, and review of facility policy, it was determined the facility failed to ensure Resident R1 was provided with the necessary equipment of wheelchair leg rest to ensure safety and proper positioning during transportation. This failure resulted in actual harm to Resident R1 who fell forward from the wheelchair and sustained a left frontal scalp hematoma and periorbital contusion for one of nine residents reviewed (Resident R1).Findings included: Review of facility policy titled Assistive Devices and Equipment revised May 2025, revealed devices and equipment that assist with resident mobility, safety and independence are provided to resident. These include a). wheelchairs (manual and powered) b). walkers and c). canes. Further review of facility policy revealed Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. Staff will be trained and will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-09-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical records, incident/accident reports, staff training records, resident and staff interviews and information submitted by the facility, it was determined that the facility failed to ensure that Resident R1 was free from neglect related to not providing the assistance of two staff during a transfer from bed to chair via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained a fall, a head injury and laceration to the head for one of three residents reviewed. This deficiency was cited as past non-compliance. (Resident R1) Findings include: Review of Resident R1's clinical record revealed the diagnoses of chronic obstructive pulmonary disease (a lung condition cause by damage and inflammation that limits airflow), age related physical debility, morbid (severe) obesity, osteoarthritis of knee (degeneration of joint cartilage), lack of coordination, muscle weakness and history of falling. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated August 2, 2024, revealed that the resident had a BIMS (Brief…
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.
- Actual harm · Gcited before2024-09-30 · 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
Based on a review of facility policies, clinical records, incident/accident reports, staff training records, and information submitted by the facility, as well as staff and resident interviews, it was determined that the facility failed to ensure resident environment remained as free of accident hazards and failed to ensure that safe techniques were used during a transfer via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained a head injury and laceration to the head for one of three residents reviewed. This deficiency was cited as past non-compliance. (Resident R1) Findings include: Review of facility policy using a mechanical lift machine dated August 2024, revealed The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; 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.
- Potential for harm · D2026-03-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatment to for pressure ulcer was obtained for Findings include:Review of the facility policy Pressure Ulcers/Skin Breakdown - clinical protocol, undated, revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nursing shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates and necrotic tissue, resident mobility status, current treatments, including support surface and relevant active diagnosis. Under Treatment/Management it further stated The practitioner will order pertinent wound treatments, including pressure reduction surfaces, would cleansing and debridement approaches, dressings (occlusive, absorptive, et)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents with a feeding tube (Resident R2) and for one resident with airborne precautions. (Residents R2 and R3).Findings include: Review of the facility policy titled Enhanced Barrier Precautions, undated, revealed: To minimize the transmission of germs transferred from residents to staff hands and clothing, staff will wear a gown and gloves when providing care to residents that require significant physical contact and are at high risk of acquiring or spreading multidrug-resistant organisms (MDROs). Enhanced barrier precautions will be applied to: (A) residents with an indwelling medical device, including a central venous catheter, urinary catheter, feeding tube (PEG tube), or tracheostomy/ventilator, regardless of their MDRO status; and (B) residents with a chronic wound, regardless of their MDRO status. Chronic wounds include pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-28 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the resident rooms, and interviews with staff, it was determined that the facility failed to maintain the Resident call bell system in working condition for two out of 10 residents' rooms observed for call bell functioning.Findings Include:On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:53 a.m., observations in room [ROOM NUMBER], Bed D, revealed the call bell device was non-functioning. Resident R2 of room [ROOM NUMBER], Bed D, stated that the call bell was not functioning for a few days.On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:57 a.m., observations in room [ROOM NUMBER], Bed B, revealed the call bell device was non-functioning.On January 28, 2026, at 11:57 a.m., the findings were confirmed with E 3, a Licensed Nurse.28 Pa Code 207.2(a) Administrator's responsibility
- Potential for harm · D2025-12-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and care plan reviews, observations of residents, policy and procedure review and interviews with staff and residents, it was determined that the facility failed to review and revise the residents care plan for three of 28 residents reviewed, in a timely manner, to ensure the greatest benefit to each resident for safety needs, hospice care, and oxygen use Residents (R4, R7, and R28) Findings include: A review of the facility policy titled care plans, comprehensive person-centered dated August 2025 revealed that it was the responsibility of the staff at the facility to develop and implement a care plan to meet the medical, psychosocial, physical and functional needs of each resident. The policy indicated that the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy also indicated that the care plan would include measurable objectives and time frames for the resident to meet their goals and attain or…
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 · D2025-12-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure physician orderes were followed for one of six residents reviewed for nutrition (Resident 110).Findings include: Review of physician orders for Resident R110, dated July 24, 2024, revealed that the resident was ordered to receive snacks at 10:00 a.m. and 2:00 p.m. review of the clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including malnutrition (lack of proper nutrition) and abnormal weight loss, and had a BIMS score of 3, indicating severe cognitive impairment. Observation conducted on December 15, 2025, at 9:30 a.m. revealed the resident had a small bag of Cheez-It crackers labeled snack 2/14. Further observations conducted on December 16 and 17, 2025, at 10:00 a.m., 10:30 a.m., 2:00 p.m., and 2:15 p.m. revealed the residents did not receive snacks per physician orders. During follow-up interview conducted with Nurse Aid, Employee E11 on December 12, 2025, at 2:11 p.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview with resident and staff as well as review of clinical record and review of facility policy, it was determined that facility did not ensure to provide appropriate treatment and services to increase range of motion and/or to prevent further decline for one of 28 residents reviewed (Resident R118)Review of facility policy Resident mobility and range of motion, revised on January 2025, indicates that residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion (ROM).Further review of policy indicates that residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.Review of Residents R118 clinical record revealed a medical history of hemiplegia and hemiparesis (weakness and paralysis) following stroke affecting left non-dominant side, need for assistance with personal care.Review of Resident R118's physician orders revealed an active order placed on December 5, 2025, 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 · D2025-12-18 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to administer pain medication in accordance with physician orders for one of three residents reviewed for pain management (Residents R84). Findings include: Review of facility policy titled Pain Assessment and Management, revised 2025, revealed pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Clinical record review revealed Resident R84 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis affecting left side (affect movement/sensation on one side of body), chronic obstructive pulmonary disease (condition that prevents airflow to the lungs, causing breathing problems), and pain. Review of Resident R84's physician's order, dated October 07, 2025, revealed an order for Percocet (opioid for moderate to severe 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.
- Potential for harm · D2025-12-18 · tag F0699 — isolatedProvide 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 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 the resident for one of three residents sampled for behavior. (Resident R45)Findings include: Review of Resident R45's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including schizophrenia (mental health condition that affects how people think, feel, and behave) and epilepsy (neurological disorder). Review of progress note for Resident R45 dated April 24, 2025, revealed that Resident R45 reported a history of sexual abuse and disclosed that the abuse occurred in the past. The note further documented that the resident was abused in the streets and around violence and reported not feeling safe in the streets.…
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 · D2025-12-18 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of resident care and services, interviews with staff and residents, clinical record and policy and procedure reviews, it was determined that for one of eight residents reviewed for nutritional needs and support with eating, the facility failed to assist each resident with obtaining routine dental care in a timely manner. (Resident R15) Findings include:A review of the facility policy titled dental services dated August 2025 revealed that it was the responsibility of the facility to ensure routine dental services was provided for each resident to meet their oral health needs. The policy indicated that a consultant dentist service was responsible to provide each resident with professional dental care. The policy also indicated that the social services department was responsible for assisting residents with timely appointments with the dental group. The policy said that all dental services provided were to be documented in the resident's clinical record. Clinical record review revealed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-01 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility provided documentation, review of closed record and interview with staff, it was determined facility did not convey the discharge summary to the continuing care provider at the time of discharge and did not contain required components for one of two closed records reviewed (Resident R2) Findings include: Review of facility policy 'Discharge summary and plan,' revised May 2025, indicates discharge summary shall include a description of the residents reconciliation of pre- and post- medications, post discharge plan of care; and any post-discharge medical and non-medical services. Review of Resident R2's clinical record on July 1, 2025, indicated that the resident was admitted to facility on August 9, 2022 and discharged on June 4, 2025. Review of discharge summary plan, completed on June 3, 2025, by Licensed nurse, Employee E3, revealed that after discharge, resident was to receive ostomy care and peg tube care. Resident R1 was discharged with active tracheostomy (tube inserted through the neck to assist with breathing) treatment. Further review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · D2025-07-01 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, review of facility policy and interview with staff, it was determined facility did not develop and implement a base line care plan for one of eight residents reviewed related to tracheostomy care and epilepsy. (Resident R1) Findings include: Review of facility policy 'Baseline Care Plan,' revised May 2025, indicates that the interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: physician orders. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE]. Further review of Resident R1's clinical record revealed physician order placed on May 22, 2025, for seizure precautions, tracheostomy (tube inserted through the neck to assist with breathing) site assessment, tracheal suction, tracheostomy care with inner cannula change and trach collar order. Further review of Resident R1's clinical record revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures. Findings include: Review of facility policy titled Food Temperatures revised January 2025, indicated that the serving temperature required for hot foods is at 135 degrees Fahrenheit (F) or above. Temperatures for cold foods, including milk and juice must be less than 41 degrees F. On February 18, 2025, at 12:00 p.m. an interview was held with Resident R14 reported warm juices and milk, those items should be cold. On February 19, 2025, at 10:30 a.m., a resident council group meeting was held with seven alert and oriented residents (R12, R15, R114, R113, R128, R30, R33) who reported concerns about the quality of meals. They stated that the food was consistently cold and repetitive, with meal temperatures remaining low. Additionally, they noted that peas and green beans were often hard and served cold. Observations during a test tray conducted with the Food Service Director (FSD), Employee E4, on February 20,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Labeling and Dating Food Items revised August 1, 2024, revealed that a visible label will be used to indicate appropriate use by date. Review of facility provided protocol, color codes for cutting boards, undated, revealed that the green cutting board is designated for ready to eat produce that will be cooked; and the red cutting board is used for raw proteins to prevent bacteria from spreading to another. A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E4, on February 18, 2025, at 10:00 a.m. Observations in the food preparation area revealed the Cook, Employee E13, was cutting chicken on the green cutting board (designated for vegetables). Observations in the refrigerator revealed nine wracks of individually sliced corn cakes, were undated and unlabeled.…
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 · D2025-02-21 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of six residents reviewed for medication safety (Resident R118). Findings include: Review of the facility policy Self-Administration of Medication dated August 2024, indicates Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove…
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 · D2025-02-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one of three nursing units. (4th [NAME] Nursing Units). Findings include: On February 18, 2025, at 12:14 p.m., an observation was made in room [ROOM NUMBER], where three mouse traps were noted. One of the traps contained mouse droppings, while another was covered in a significant amount of dust which looked like a dead mouse. The room's floors were observed to be dirty, with visible crumbs and spills present. Additionally, the trash can was dirty with brown substances and did not have a linen trash bag. During an interview, Resident R8 stated that housekeeping had entered to clean the room; however, the floor mats on both sides of the bed remained unclear with spills. These observations were confirmed by Licensed Nurse Employee E7. On February 18, 2025, at 12:14 p.m., additional observations with Licensed Nurse, Employee E7, confirmed that there were…
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 · D2025-02-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observations, and interview with residents and staff, it was determined that the facility failed to provide bathing support and feeding assistance for two of two residents sampled for activities of daily living (Resident R39 and Resident R73). Findings Include: Observation of the Resident R73 on February 18, 2025, at 1:00 p.m. revealed that the resident had beard and disheveled hair. Interview with Resident R73 on February 18, 2025, at 1:00 p.m. stated he wanted to shave and cut his hair, but staff did not offer him any help. Resident stated staff sometimes gave him bed bath but very rarely offered shower. Review of MDS-Minimum Data Set-Assessment of resident care needs for Resident R73 dated November 26, 2024, revealed that the resident had a BIMS score of 15 which indicated that the resident's cognitive status was intact. Further review of the MDS revealed that the resident required substantial/maximal assistance for shower or bathing. Review of shower documentation for Resident R73 revealed that the resident was scheduled for shower on Wednesday…
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 before2025-02-21 · 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
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that prescribed wound care treatments were not left at the bedside for one of 31 residents reviewed. (Resident R60) Findings include: Review of Resident R60's Minimum Data Set (MDS - a periodic assessment of care needs) dated November 26, 2024, indicates the diagnosis of anemia (low iron in the blood) and dementia (loss of intellectual functioning). During an observation completed on February 18, 2025, at 1:00 p.m. Resident R60 was sitting in his bed and eating his lunch from a lunch tray. It was observed that there was open bottle of Dakin's wound care solution sitting next to the lunch tray which the resident was eating. When asked the resident what was inside the bottle, resident stated water. Surveyor immediately notified Employee E16, Licensed Practical Nurse. Further observation revealed that there was wound cleanser and wound care supplies sitting on top of resident's nightstand. Interview with Employee E16 stated that was open bottle of Dakin's solution with medication…
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 before2025-02-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's and administering oxygen as ordered by the physician for one of 31 residents reviewed. (Resident R19). Findings Include: Review of the facility policy Nebulizer Administration, dated January 2025 revealed that Rinse nebulizer, mouthpiece, and T piece with tap water and let air dry. a. Date and place supplies in a treatment bag. b. Replace and date the setup every seven days. c. Check compressor for air filters that require replacement and cleaning every 30 days. d. Follow manufacturer's instructions. e. Disinfect the outside of the compressor between use of Elders/residents/guests and as needed. Review of the facility policy Oxygen Administration, dated January 2025 revealed that Replace entire set-up every seven days. Date and store in treatment bag when not in use. If using a non-disposable humidifier, change bottle every seven days and change water every 24 hours to prevent bacterial…
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 before2025-02-21 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, and staff interviews, it was determined that the facility failed to ensure the identified pharmacy review irregularities were implemented for two of five residents reviewed (Resident R118 and R104). Findings Include: Review of physician order for Resident R104 dated July 30, 2024 revealed an order for Nifedipine(antihypertensive medication), give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure less than100 or heart rate less than 60 Review of Resident R104's Consultant Pharmacist review report dated December 24, 2024, by consultant pharmacist, revealed a recommendation, Medication error noted. Nifedipine (antihypertensive medication) is not always held as required by the physician's hold order on 12/5, 12/6, 12/9, 12/10, 12/14, 12/15, 12/17, 12/18, 12/19 and 12/20. Heart rate was less than 60 (per MAR)(medication administration record) and the medication was still administered. Further review of the report revealed that the recommendation was completed on January 3, 2025. Review of Resident R104's Consultant…
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 · D2025-02-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, review of clinical record, observations and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for one of 31 residents reviewed (Resident R83). Findings include: Review of facility policy Thickened Liquids dated January 2025 revealed that A written order for thickened liquids will be communicated to the dietary department via diet requisition form. 3. The order will specify one of the following levels: a. Nectar - consistency of a thin milkshake or eggnog; should be semi-thick and pourable. b. Honey- consistency of honey at room temperature, or a thick milkshake; should be pourable. c. Pudding - consistency of pudding, with thickened liquid not runny but dropping in one semi-solid mass, should be spoon able but not pourable. 4. Residents who require thickened liquid will be provided pre-packaged thickened liquids (per the ordered consistency), or will be provided liquids thickened prior to service by a staff member who has completed education in thickening liquids.…
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 · D2025-02-21 · tag F0920 — isolatedProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, it was determined that the facility failed to provide sufficient space for residents for dining services for two of three dining room revealed. (Third floor and Fourth floor) Findings include: Observation on February 19, 2025, at approximately 12:10 p.m., revealed that the lunch service was provided at the dining room on fourth floor. There were 12 residents sitting in the dining room which was congested and did not have space for staff to move around and place the meal trays. There were 8 residents sitting across the door which could not move of leave the dining room until four residents in the middle-finished eating. Observation on February 19, 2025, at12:00 p.m., revealed that the lunch service was provided at the dining room on the third floor. There were approximately 14 residents sitting in the dining room, It was observed that the staff moved a resident sitting in the middle of the room to outside of the dining room to create space for staff to move around inside the dining room. It was also observed that there were 2…
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 · D2024-12-05 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that medically-related social services were provided as required for one of 4 residents reviewed (Residents R1). Findings include: Interview on December 5, 2024, at 9:30 a.m. with Resident R1 stated that she wanted to transfer to another facility because she did not like it here, and that there were no staff at the facility to assist her and her daughter in planning this transfer. Resident R1 expressed that he she was frustrated because her daughter requested to speak with the social worker since admission on [DATE]. Review of Resident R1's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), revealed that the resident was admitted to the facility on [DATE], and had a BIMS (Brief Interview for Mental Status) score of fifteen (15), indicating that the resident was cognitively intact. Review of Resident R1's clinical record revealed a nursing…
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 · D2024-04-05 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and interviews with resident and staff, it was determined that the facility did not ensure one resident's rights were exercised related to scheduled dialysis appointments for one of 27 resident records reviewed (Resident R22). Findings include: Review of Resident R22's clinical record revealed the resident was admitted to the facility on [DATE], independent in making personal decisions, diagnosed with End Stage Renal Disease (kidney failure) and Chronic Obstructive Pulmonary Disease (COPD a lung disease). During an interview with Resident R22 on April 2,2024 at 11:30 a.m. stated that resident went to Dialysis (treatment for kidney failure) three times a week. She stated she used to go early in the morning and enjoyed the earlier schedule much more but the facility changed it to later in the day. Interview with the Director of Nursing (DON) on April 4, 2024 at 1:00 p.m. stated, We changed Resident R22's dialysis time because she needed an escort and she agreed to the change.…
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 · D2024-04-05 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a mid line catheter in accordance with professional standards of practice for one of one resident with midline reviewed (Resident R113). Findings include: Review of facility policy, PICC, Central Line and Perpheral Line Dressing Changes dated July 2019 revealed that Central venous access devise and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture drainage or blood is present or for futher assessment if infection is suspected. Transparent semi-permeable membrane dressing are changed every 7 days and PRN. Observation of Resident R113 on April 2, 2024, at 12:14 p.m, revealed that the resident had a right upper extremity mid line insertion. There was documentation on the dressing to indicate the date and time 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 · Dcited before2024-04-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure to administer oxygen therapy in accordance with professional standards of practice related to for two of 28 residents reviewed (Resident R18 and R22). Findings include: Review of facility's policy titled 'Oxygen Administration,' revised on August 2000, states nasal cannula or mask and oxygen tubing must be dated and changed weekly. Review of R18's clinical records revealed diagnosis of chronic obstructive pulmonary disease, high blood pressure, heart disease, kidney disease - stage 3. Observations of R18 on third floor unit, on April 2, 2024 at 11:31 am revealed oxygen tubing dated February 17, 2024; finding confirmed by licensed nurse, employee E3. Review of Resident R22 clinical record revealed the resident was admitted to the facility on [DATE] diagnosed with End Stage Renal Disease (kidney failure) and Chronic Obstructive Pulmonary Disease (COPD a lung disease). Further review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-05 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical documentation, and interviews with staff, determined the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, by failing to provide dialysis treatment and medication as ordered for one of 34 resident records reviewed (Resident R22). Findings included: Review of the facility's policy titled, Dialysis Care Policy stated it is the facility's policy to coordinate dialysis care and services for residents receiving dialysis in a comprehensive manner and coordination of services between the facility and the dialysis center to maintain continuity of care. Review of Resident R22's clinical record revealed the resident was admitted to the facility on [DATE], independent in making personal decisions, diagnosed with End Stage Renal Disease (kidney failure) and received hemodialysis. Review of Resident R22's nursing progress notes revealed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, review of clinical records, and interview with staff, it was determined the facility did not ensure to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for three of 28 residents reviewed. (Residents R32, R35, and R97) Findings include: Review of facility's policy titled 'Medication Administration,' revised on May 2020, indicates that drugs are to be administered in accordance with the written orders of the attending physician. When a resident's medication has not been delivered from pharmacy; the licensed nurse should immediately notify the pharmacy and notify a unit manager or nursing supervisor to obtain the medication from the medication dispense. Review of Resident R32's April 2024 physician orders revealed an order for Aspirin 81 milligrams (mg) delayed release to be administered once a day at 9:00 a.m. Continued review of phycisian orders revealed an order for Nifedipine 60mg extended release to be administered once a day at 9:00 a.m. Observations during medication…
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 before2024-04-05 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies, clinical records and interviews with staff, it was determined that the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included time frames for the different steps in the medication regimen review process and act on irregularities reported by the licensed pharmacist during monthly drug regimen reviews in a timely manner for one of five residents reviewed related to medication regimen reviews (Residents R55). Findings include: 1. Review of facility policy Medication Regimen Review dated April 2024 revealed that Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. The pharmacist must report any irregularities to the attending…
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 · D2024-04-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to offer and/or provide the pneumococcal immunization to two of five residents reviewed (Resident R18 and R33). Findings include: Review of an undated facility policy Pneumococcal Vaccine: dated revealed that Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated will be offered the vaccine unless medically contraindicated or the resident has already been vaccinated. Review of Resident 117's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Review of clinical record revealed that the resident was [AGE] years of age. Review of R83's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Review of clinical record revealed that the resident was [AGE] years of age.…
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 before2023-08-23 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews with residents and staff, it was determined that the facility failed to ensure that the resident call systems were maintained in proper working order on one of three nursing floors. (Third Floor) Findings include: Observation of Resident R1, on August 23, 2023 at 10:46 a.m., during tour of the facility revealed that Resident R1 was in her room calling for help. The surveyor activated the call bell and the call bell was found to be non functional. There was no alert at the nurses station, and no light above the resident's door in the hallway to signal a residents call. Interviews conducted on the Third floor nursing unit with Residents R2, R3 and R4 on August 23, 2023 between the hours of 10:00 a.m. and 11:30 a.m. revealed that the residents were not satisfied with the call bell response times, related to their requests for staff assistance with care, after activating the nursing call system. Interview with Resident R4 revealed that the call bell was never answered. Surveyor requested Resident R4 to activate the call bell, after ten minutes, there…
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 · B2024-09-19 · 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 — the official record, unedited, may be distressing
Based on clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate discharge notices were provided to the office of the long-term care ombudsman for the following months: January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024. Findings include: A review was conducted of facility records. The review did not reveal documentation that the required notifications were sent to the state office of the long-term care ombudsman for facility-initiated transfers and discharges during the period examined. Interview with the Executive Director, employee E1, on September 19, 2024, at 1:00 p.m. confirmed that the notifications for January 2024 through July 2024 had not been sent to the ombudsman's office in a timely manner as required. 28 Pa. Code 201.18(b)(3) Management
“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
$25,847 in federal fines across 2 penalties.
- $12,923 — penalty dated 2024-09-30
- $12,924 — penalty dated 2024-09-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ALLAIRE HEALTH SERVICES — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 1 of 5 | 3.1 | -2.1 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 19 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GOLDSCHMIDT, CHAVA | Individual | DIRECT OWNERSHIP INTEREST | since 08/01/2024 |
| KURLAND, BENJAMIN | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| RUBIN, ISAAC | Individual | DIRECT OWNERSHIP INTEREST | since 08/01/2024 |
| 4401 HAVERFORD AVE LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 01/24/2025 |
| PANCHAL, VIMMIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| RINGKAMP, FRANCIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| GV CONSULTING | Organization | ADP OF THE SNF | since 08/01/2024 |
CMS files one row per role, so the 12 rows in the source record cover these 7 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.
2 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 $3K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395686. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, 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.