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Whitehall Borough Post Acute

505 Weyman Road, Pittsburgh, PA 15236 · For profit - Limited Liability company · 166 certified beds · (412) 884-3500 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0603) — most recent Jun 2024Resident-funds citation (F0565)1 immediate-jeopardy citation$45,050 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0603) — most recent Jun 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $45,050 in federal fines (most recent 2026-05-07)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • about 24% of its spending goes to commonly-owned related companies

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 4 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
5301 Grove Rd · (412) 881-4377 · Call to confirm hours
Pharmacy
Pharmacy0.3 mi
5260 Grove Road, Baptist & Grove Roads
Grocery
5260 Grove Road, Baptist & Grove Roads
Park
4700 Baptist Rd · Typically dawn to dusk
Place of worship

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 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.0%16.8%15.4%better
Long-stay residents who lose too much weight0.9%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms50.7%10.8%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury1.0%3.1%3.3%better
Long-stay residents whose ability to walk worsened9.8%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.0%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine94.4%93.5%95.3%typical
Long-stay residents with pressure ulcers3.3%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control19.1%25.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.2%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine69.3%68.7%79.4%worse
Short-stay residents rehospitalized after admission24.8%22.5%22.6%typical
Short-stay residents with an outpatient ER visit10.7%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.201.621.67better
Long-stay outpatient ER visits per 1,000 resident days0.621.181.80better

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.

48.3% 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 274 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.3%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
68.4%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 68.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 95 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF48.3%CMS range 43.1–53.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.1–14.110.7%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 discharge68.4%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 discharge60.0%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 discharge67.4%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 identified95.5%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 setting98.4%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 stay0.8%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 worsened0.8%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 hospitalization8.3%CMS range 4.6–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 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

0.99
RN hours/ resident / day
0.50
LPN hours/ resident / day
1.96
Aide hours/ resident / day
3.45
Total nurse hours/ resident / day
0.82
RN hoursweekends
50.3%
Total nursing turnover
39.1%
RN turnover

How full it usually is: this home is certified for 166 beds and averages 144.4 residents a day — about 87% occupied, or roughly 22 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.16 hrs/resident/day on weekends vs 3.56 on weekdays — 11% thinner on weekends. RN hours go from 1.06 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

6
deficiencies at the latest standard inspection (2026-05-07)
5
at the previous standard inspection (2025-05-16)

Deficiencies are more than at the previous inspection — worsening. 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.

33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 facility review of policy, manufacturer's instructions, clinical records, and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 7 of 36 residents (R3, R17, R64, R84, R116, R145, and R148).Findings include: Review of the facility policy, Hypoglycemia Management Policy dated 1/6/26, indicated:Administer 15 grams of fast-acting carbohydrateRecheck blood glucose in 15 minutesIf BG remains less than 70 mg/dl, repeatNotify provider Review of the facility policy, Physician Notification Policy dated 1/6/26, indicated, Notification will be based on resident's condition, clinical judgement, practitioner orders, and applicable regulatory requirements. Documentation should reflect relevant clinical findings, practitioner communication when completed, orders or recommendations received, and actions taken by…

    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 · E2026-05-07 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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

    Based on review of facility policy, observation and resident and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for two of four nursing units as required (TCU 1st. floor, and ARU1). Findings included: Review of the facility policy Homelike Environment, dated 1/6/26, indicated the staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. Observations on 5/4/26 at 10:38 a.m. and 5/725, at 8:30 a.m., revealed the following:Resident rooms122, 125, 129, 133, 137, and 141 had wallpaper peeling off the walls. Resident room126 had a large stain on the ceiling. Resident room145 had a hole in the wall. During an interview on 5/7/26 at approximately 9:15 a.m., the Nursing home Administrator confirmed the conditions of the residents' rooms. Observations on 5/7/26 at 8:45 a.m. revealed the following:Resident rooms404B and 405B had deep scratches in the walls near 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-07 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to the use of ACE wraps (elastic bandages) for 11 of 14 residents (Resident R16, R32, R50, R62, R74, R97, R117, R123, R130, R147, and R174).Findings include: During the observations were completed on 5/4/26, at approximately 12:00 p.m., on 5/4/26, at approximately 2:45 p.m., on 5/5/26, at approximately 2:15 p.m., on 5/6/26, at approximately 11:00 a.m., and on 5/7/26, at approximately 12:00 p.m. All observations on 5/7/26, were confirmed by the Assistant Director of Nursing. Review of Resident R16's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated included diagnoses of dated 4/22/26, included diagnoses of high blood pressure (hypertension) and lymphedema (the build-up of fluid in soft body tissues). Review of a physician…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-07 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for seven of 36 residents (R3, R17, R64, R84, R116, R145, and R148).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The primary purpose of your job position is served as a licensed skilled nursing facility administrator, directing the day-to-day functions of an independent skilled nursing facility in accordance with federal, state, and local requirements that govern skilled nursing facilities, thus seeking to assure that the facility provides a high degree of quality of care to its residents. Review of the facility-provided Director of Nursing (DON) job description indicated the essential duties of the DON include the overall management of the entire nursing department and staffing levels, develop 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-07 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for three of eight residents (Residents R13, R48 and R75). Findings include: Review of the facility policy, Physician/Practitioner Orders Policy dated 1/6/26, indicated to provide a general process for receiving, reviewing, implementing, clarifying, and documenting physician/practitioner orders while the resident is under the care of the facility. The facility will obtain and implement physician/practitioner orders in a manner to support resident care needs. Review of the facility policy, Wound Management Policy dated 1/6/26, indicated care may be provided by practitioner orders and wound nurse recommendations. Documentation should reflect the care provided and may be completed in the treatment record. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of the Minimum…

    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 · E2026-05-07 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the clinical records, staff interviews, facility documents, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively for seven of 36 residents (Resident R3, R17, 64, R84, R116, R145, and R148).Findings include: Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Program dated 1/6/26, indicated the QAPI plan describes the process for identifying and correcting quality deficiencies. Listed as a Key Component of the process was, monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. During the survey process the following was revealed: -Resident R3 had 20 instances of high or low blood sugar levels without documentation that the medical provider was notified. -Resident R17 had 15 instances of high or low blood sugar levels without…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · 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 clinical records and staff interview, it was determined that the facility failed to provide adequate supervision to avoid injuries for one of three residents (Resident R1). Findings include:Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/16/25, included diagnoses of COPD, muscle weakness, and the need for aftercare following joint replacement surgery. Review of Section G: Functional Status indicated that Resident R1 required supervision for eating. Review of Resident R1's plan of care for ADL (activities of daily living)/mobility dated 7/11/25, indicated for staff to monitor for changes or decline in ability to participate in ADLs, decreased strength, increased weakness, or changes in cognition. Further review of the care plan failed to reveal documentation of the needed assistance level during meals. Review of a progress note dated 8/18/25, at 10:00 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-16 · tag F0628 — pattern
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy and documents, information provided by the State Ombudsman Office, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization (Resident R6, R89, R123, and R138) and failed to notify the State Ombudsman Office of resident transfers and discharges for two years (11/2023 through 12/2023, 1/2024 through 12/2024, and 1/2025 through 4/2025) as required. Findings Include: Review of federal regulation §483.15(d) Notice of Bed-Hold Policy, indicated: -Facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. -The first…

    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 · E2025-05-16 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set ( MDS - periodic assessment of resident care needs) assessments accurately reflected the resident's status for two of eight residents (Resident R30 and R50). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: -Section I: Active Diagnoses, that a diagnosis should be checked if they had had an active diagnosis for a disease or condition in the last seven days. -Section O: Special Treatments, Procedures, and Programs: Review the resident ' s medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-16 · tag F0761 — failed to label and store drugs safely — pattern
    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, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in two of three medication rooms (First and Second floor medication rooms) and two of five medication carts (MedBridge A-hall, MedBridge B-hall). Finding include: Review of facility policy Storage and Expiration Dating of Medications, Biologicals dated [DATE], stated that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The policy further stated that multiple dose injectable vials and ophthalmics, once opened, require an expiration date shorter than the manufacturer ' s expiration date to insure medication purity and potency. Review of the facility provided document, Medications with Shortened Expiration Dates indicated Aplisol…

    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 · D2025-05-16 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify resident representatives of a transfer to the hospital for one of five residents (Resident R89). Findings include: Review of the facility policy, Change in Condition Notification dated 3/4/25, indicated the facility will will promptly notify the resident's family or designated representative of any significant change in the resident's physical, mental, or psychosocial condition. Notification will occur as soon as possible and no later than 24 hours from the time the change is identified. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R89 was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · Dcited before2025-05-16 · 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 review of clinical records, and staff interview it was determined that the facility failed to provide appropriate treatment and care for one of four residents (Resident R21) Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/23/25, included diagnoses dementia (a group of symptoms that affects memory, thinking and interferes with daily life), muscle weakness and wasting, and a seizure disorder. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of 99, meaning that Resident R21…

    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 before2025-02-20 · 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

    Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly secured in one of two medication carts (Second-floor medication cart for rooms 220-231). Findings include: Review of the facility policy Medication Storage dated 2/10/25, indicated medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access. During an observation on 2/20/25, at 11:50 a.m., the 220-231 medication cart was observed unlocked. The surveyor remained with the medication cart. At approximately 11:54 a.m. the surveyor opened the medication cart drawers and observed that the drawers were not secured. The surveyor reviewed the medication cards. At approximately 11:58 a.m. LPN Employee E2, was requested to confirm the medication cart was unsecured. LPN Employee E2 located Registered Nurse (RN) Employee E1 on the unit who confirmed that the medication cart was unsecured. During an interview on 2/20/25, at approximately 3:00 p.m., the 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-12 · tag F0761 — failed to label and store drugs safely — pattern
    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

    Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to properly secure medication in one medication refrigerator (Family Conference room), and one of three medication carts observed (ARU 1 nursing unit). Findings include: Review of the facility policy Medication Labeling and Storage reviewed 1/30/24, indicated the facility stores all medications and biologicals in locked compartments. Compartments 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. Medications requiring refrigeration are stored in a refrigerator located in the medication rooms at the nurse ' s station or other secured location. During an observation on 12/12/24, at 9:00 a.m. an unlocked medication refrigerator located in the Family Conference room by the front lobby, was accessible to visitors, family, and residents. The refrigerator contained three unopened vials of influenza vaccine, one opened vial of influenza…

    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 · D2024-12-12 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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, resident interview, observations, and staff interview it was determined the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents (Resident R1 and R2). Findings include: Review of facility policy Self-Administration of Medications last reviewed 1/30/24, indicated 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. If it is deemed safe and appropriate for a resident to self-administer medications it is documented in the medical record and the care plan. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, muscle weakness, and chronic obstructive pulmonary disease (COPD - caused by swelling 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of seven residents (Resident R3). Findings include: Review of the facility policy Abuse Prohibition reviewed on 1/30/24, indicated the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will initiate and investigation within 24 hours. Review of the facility policy Accidents and Incidents - Investigation and Reporting reviewed 1/30/24, indicated all accidents or incidents involving residents, employees, vendors, etc., occurring on our premises shall be investigated and reported by the administrator. A review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-09 · tag F0761 — failed to label and store drugs safely — widespread
    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, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in three of three medication carts (Medbridge B-hall, Medbridge A-hall, and the TCU-1 medication carts). Findings include: Review of facility policy Storage and Expiration Dating of Medications, Biologicals dated [DATE], stated that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy or supplier. During an observation of the Medbridge B-hall medication cart on [DATE], at 3:10 p.m. the following was observed: -Two bottles of Fluorometholone eye drops, opened, partially used, and undated. -One bottle of Olopatadine eye drops, opened, partially used, undated, and without a resident name. -One bottle of artificial tears eye drops, opened, partially…

    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 · Ecited before2024-09-09 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of 12 residents (Residents R1, R2, R3, R4, R5, R6, and R7). Findings Include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident's activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. During an interview on 9/8/24, at 1:58 p.m. Resident R1, when asked if she felt the facility maintained sufficient staff, stated, No. When asked if call lights took a long time to be answered, stated, Sometimes it's a good while. I pushed it yesterday and waited and waited. During an observation on 9/8/24, at 2:01 p.m. Resident R2 was observed to have untrimmed facial…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-13 · tag F0603 — failed to not confine residents against their will — isolated
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and resident and staff interviews, it was revealed that the facility failed to prevent involuntary seclusion for two of 10 residents reviewed (Resident R1, and R2). Findings include: Review of the facility policy Abuse Prohibition reviewed 1/30/24, indicated the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Involuntary seclusion is defined as separation of a resident from other residents or from their room or confinement to their room against the resident's will or the will of the resident's legal representative. Neglect is defined as the failure, indifference, or disregard to provide care, comfort, safety, goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-13 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 review, facility documentation, and staff interview, it was determined that the facility failed to ensure two of 10 residents observed (Resident R1, and R2) were free from physical restraints by being pushed up to a table with a wheelchair blocking the side exit. Findings include: Review of the facility policy Abuse Prohibition reviewed 1/30/24, indicated the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Involuntary seclusion is defined as separation of a resident from other residents or from their room or confinement to their room against the resident's will or the will of the resident's legal representative. Neglect is defined as the failure, indifference, or disregard to provide care, comfort,…

    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
  • Potential for harm · E2024-05-09 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to protect residents from staff initiated verbal abuse for two of nine residents (Resident R74 and R156). Findings include: A review of facility policy Abuse Prohibition, dated 1/30/24, indicated the facility prohibits abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporeal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the patient's medical condition. The policy further defined Verbal Abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are limited to threats of harm,…

    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
  • Potential for harm · E2024-05-09 · tag F0636 — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS- periodic assessment of care needs) assessments were completed in the required time frame for 12 of 16 residents (Resident R104, R120, R262, R263, R264, R265, R320, R321, R322, R362, R363, and R364). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS, dated [DATE], indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R263 had an admission date of 4/19/24, with an MDS completion due date of 5/2/24, this was not completed as of the end of the survey on 5/9/24. Resident R321 had an admission date of 4/19/24, with an MDS completion due date 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-09 · tag F0655 — pattern
    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 policy, clinical record reviews and interviews with staff, it was determined that the facility failed to establish a baseline care plan within 48 hours of admission/readmission for three of twelve residents (Resident R61, R72 and R324). Findings include: A review of facility policy Person Centered Care Plan reviewed 1/30/24, indicated it is the policy of this facility to develop and implement a baseline person-centered care plan for each resident within 48 hours of admission/readmission that will include the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses that included fracture of left femur (a break in the long bone in the thigh), high blood pressure, repeated falls, and dementia (group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record review and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for three of six residents (Resident R74, R85, and R124, R328). Findings include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident's activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. Review of Resident R74's admission record indicated that Resident R74 was admitted to the facility on [DATE], with diagnoses that included kidney failure, neurocognitive disorder (decreased mental function and loss of ability to do daily tasks), diabetes, and obesity. Review of Resident R74's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 3/8/24, indicated that diagnoses…

    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 · Ecited before2024-05-09 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policies and documents, resident observations, resident and staff interviews, and resident care records, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of nine of 32 residents (Resident R74, R85, R124, R128, and R328) and four of nine group residents (R401, R402, R403, and R404). Findings Include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident ' s activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. During an interview on 5/6/24, at 1:10 p.m. Registered Nurse (RN) Employee E12 stated that the staffing is not adequate. When asked what care was not being provided consistently to the residents, RN Employee E12 stated that there is not time to get showers completed on the weekends,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the Long-Term Care Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to transmit Minimum Data Set's (MDS -periodic assessment of care needs) to the required electronic system within the mandated time frame for one of 16 residents reviewed (Resident R20). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2023, indicated that Entry, Death and Facility and Discharge tracking MDS assessments must be completed and transmitted within 14 days of the event date. Resident R20 had a discharge date of 4/17/24, with a Discharge/Return Anticipated MDS completion due date of 5/1/24, this was not completed until 5/7/24, six days later. During an interview on 5/9/24, at approximately 11:00 a.m. the RNAC (Registered Nurse Assessment Coordinator) Employee E1 confirmed the above assessment was not completed, due to a lack of sufficient staff. During an interview…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of four residents (Resident R128). Findings include: Review of the facility policy Skin Integrity and Wound Management dated 1/8/24, previously dated 3/28/23, indicated the facility will provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. Review of the clinical record indicated Resident R128 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 3/6/24, included the diagnoses of history of a stroke, hemiplegia (paralysis on one side of the body), and the need for assistance with personal care. Review of Section C - Cognitive Patterns indicated that Resident R128 was cognitively intact. Review of Section GG - Functional…

    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 · E2024-04-08 · tag F0836 — pattern
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements. Findings include: Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12, dated 7/1/23, indicated the following subsections. (f.1) In addition to the director of nursing services, a facility shall provide all of the following: (2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight. (i) A minimum number of general nursing care hours shall be provided for each 24-hour period as follows: (1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident. Review of facility surveys completed since 7/1/23, through 4/7/24, revealed the following: Survey of 7/14/23: -Failed to…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident council group meeting minutes, resident and staff interview it was determined that the facility failed to answer call bells in a timely manner for six of six residents observed and failed to have an ample linen supply at the staffs immediate disposal (Residents R1, R2, R3, R4, R5, and R6). Findings include: The facility Call Lights policy dated 2/1/23, indicated that all residents will have a call light within their reach at all times when unattended. Staff will respond to call lights promptly. The facility Accommodation of Needs policy dated 2/1/23, indicated the Center's physical environment and staff behaviors should be directed toward assisting the patient in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible in accordance with the patient's own needs and preferences. Review of Resident Council Group Minutes dated 10/27/23, indicated that they are often short on linens, agency staff are not always…

    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 · D2023-12-19 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, resident council minutes, group and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for two of two months (October through November 2023). Findings include: Review of the facility policy dated 8/7/23, Resident Council indicated: -The designated staff person acts as a liaison between the Council and Center/Community leadership in providing information on concerns, requests, and recommendations to the Administrator and the appropriate department manager for attention and response. -Responses and rationale will be documented reviewed by the Administrator and maintained with the Council Minutes. -Grievances and concerns are documented on the Grievance/Concern Form in accordance with established policy. A copy of the resolution is to be maintained with the Council Minutes. Review of resident council minutes from October to November 2023 indicated the following concerns: -October 27, 2023 resident meeting indicated the facility was often short 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-05 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, and staff interviews it was determined that the facility failed to keep essential equipment in working order from July 2023 till October 2023. Findings include: Review of facility documentation resident council minutes dated 8/25/23, indicated that residents had concern over linens. During an interview on 10/5/23, at 11:40 a.m. Maintenance Director Employee E1 confirmed that the facility has three commercial washing machines for residents linen/clothing; first washing machine stopped working in July. In addition a second washing machine stopped working during the same time period. During the same interview Employee E1 confirmed that two washing machines were broken and only one washing machine was working. During an interview on 10/5/23, at 4:00 p.m. Maintenance Director Employee E1 confirmed that the second washing machine did not get fixed till this week (Tuesday 10/3/23). During the above interview Maintenance Director E1 was asked why it took several months to get all the washing machines fixed, and Employee E1 confirmed that the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-05-09 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for four of ten staff members (Employees E2, E3, E4, and E5). Findings include: Review of the facility policy In-service Training dated 1/8/24, previously dated 3/28/23, indicated all mandatory in-service requirements must be completed annually as a condition of continued employment. Listed in the training topics to include: Quality assurance and performance improvement (QAPI) training on the elements and goals of the QAPI program. Review of facility provided documents and training record for Employees E2, E3, E4, and E5 revealed the following staff members did not have documented training on QAPI. Nurse Aide (NA) Employee E2 had a hire date of 2/26/07, failed to have QAPI in-service education between 2/26/23, and 2/26/24. NA Employee E3 had a hire date of 3/23/09, failed to have QAPI in-service education between 3/23/23, and 3/23/24. NA Employee E4 had a hire date of 1/3/18, failed to 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-05-09 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide (NA)Employees E2 and E3). Finding include: Review of the facility policy In-service Training dated 1/8/24, previously dated 3/28/23, indicated all mandatory in-service requirements must be completed annually as a condition of continued employment and further stated the facility will ensure continuing competence for no less than 12 hours per year for nurse aides. Review of NA Employees Employees E2 and E3 education records with hire date greater than 12 months revealed the following: NA Employee E2 had a hire date of 2/26/07, with 9:05 hours in-service education between 2/26/23, and 2/26/24. NA Employee E3 had a hire date of 3/23/09, with 9:05 hours in-service education between 3/23/23, and 3/23/24. During an interview on 5/9/24, at approximately 1:00 p.m. the Nursing Home Administrator…

    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.

    Nursing and Physician Services 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

$45,050 in federal fines across 1 penalty.

  • $45,050 — penalty dated 2026-05-07

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 PACS GROUP — 274 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 2 of 52.9-0.9 vs chain
Health inspection 1 of 52.5-1.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; 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
APT, FREDERICKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2024
JERGENSEN, JOSHUAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2024
MITCHELL, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2024
PACS GROUP, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2024
PACS HOLDINGS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2024
PROVIDENCE GROUP NH, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2024
PA HOLDCO 1 WHITEHALL LLCOrganizationADP OF THE SNFsince 11/01/2024
PA HOLDCO 2 WHITEHALL LLCOrganizationADP OF THE SNFsince 11/01/2024
HANCOCK, MARKIndividualADP OF THE SNFsince 11/01/2024
MURRAY, JASONIndividualADP OF THE SNFsince 11/01/2024

CMS files one row per role, so the 16 rows in the source record cover these 10 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.

5 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.

$20.3M
Net patient revenuemost recent cost report
-6.4%
Operating marginrevenue minus expenses
$5.3M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 7%Other / private 29%

This home reported $5.3M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$381per resident / day
operating cost
$11,568per month
≈ monthly operating cost
$358per day
avg. revenue, all payers

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

Paying with Medicaid

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.

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 396066. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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