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Wesley Village

209 Roberts Road, Pittston, PA 18640 · Non profit - Corporation · 160 certified beds · (570) 655-2891 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citations — no harm found (F0740, F0758)1 immediate-jeopardy citation$8,021 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,021 in federal fines (most recent 2024-07-19)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
42 N Main St · (570) 602-5610 · Call to confirm hours
Pharmacy
200 Overlook Dr Ste 319 · (570) 655-6222 · Call to confirm hours
Grocery
220 E 7th St · (570) 693-2870 · Call to confirm hours
Park
12 Main St · 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 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased26.6%16.8%15.4%worse
Long-stay residents who lose too much weight1.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder1.1%0.7%0.9%worse
Long-stay residents with a urinary tract infection2.4%1.5%2.0%worse
Long-stay residents with depressive symptoms0.3%10.8%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.5%3.1%3.3%worse
Long-stay residents whose ability to walk worsened30.8%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication10.4%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine97.0%93.5%95.3%typical
Long-stay residents with pressure ulcers4.7%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control31.7%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.6%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine91.5%68.7%79.4%better
Short-stay residents rehospitalized after admission24.8%22.5%22.6%typical
Short-stay residents with an outpatient ER visit12.8%9.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.851.621.67worse
Long-stay outpatient ER visits per 1,000 resident days1.161.181.80better

§ 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.

54.7% 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 448 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.7%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
55.3%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 55.3% 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 246 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNF54.7%CMS range 50.1–59.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 7.5–11.910.7%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 discharge55.3%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 discharge50.0%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 discharge48.4%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 identified92.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 4.0–8.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 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

0.72
RN hours/ resident / day
1.05
LPN hours/ resident / day
2.18
Aide hours/ resident / day
3.95
Total nurse hours/ resident / day
0.45
RN hoursweekends
47.7%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 160 beds and averages 113.4 residents a day — about 71% occupied, or roughly 47 beds typically open. It usually has some room. 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 3.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.42 hrs/resident/day on weekends vs 4.16 on weekdays — 18% thinner on weekends. RN hours go from 0.83 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% 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 (2026-02-13)
8
at the previous standard inspection (2025-05-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · J2024-08-16 · 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 observations, a review of clinical records, select facility policy, resident incident/accident report and staff interviews, it was determined that the facility failed to provide adequate staff supervision and effective safety measures to prevent elopement for two residents (Resident CR1 and Resident 2) out of 4 residents reviewed, The facility further failed to identify staff's reliance on the facility's alarm system to prevent elopements and the deficiencies of this system to prevent future unsupervised exits from the facility, which placed residents in immediate jeopardy of future unsupervised exits from the facility and the potential for serious bodily injury or death. Findings include: A review of a policy entitled Wandering and Elopement Risk Identification and Management, dated September 2021, states it is the policy of the facility to maintain facility wide systems and resident specific plans of care to minimize resident risk and potential for harm related to wandering and elopement. Definition:…

    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 before2026-02-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department.Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observations during the initial tour of the kitchen conducted with the facility's Food and Nutrition Services Director on February 10, 2026, at 8:50 AM revealed the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-13 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to ensure residents are afforded the opportunity to make informed treatment decisions and choose preferred alternatives for one out of four residents sampled for a closed record review (Resident 128).Findings include: Clinical record review revealed Resident 128 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 21, 2025, revealed Resident 128 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess 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 · Dcited before2026-02-13 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record and select policy review, staff and resident interviews, it was determined the facility failed to timely assess and implement interventions to address one of 25 residents' pain (Resident 2).Findings include:A review of the facility's pain management policy dated March 19, 2025, revealed that it was the goal of the facility to promote the highest practicable level of physical, mental, and psychological well-being, in accordance with the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences. The pain management policy also indicated the resident will have pain identified and assessed. The type of pain will be identified for appropriate management approaches to alleviate/eliminate the resident's pain. A review of Resident 2's clinical record revealed the resident had a diagnosis of muscle weakness and diabetes (a chronic condition causing high blood sugar due to insufficient insulin production). An admission Minimum Data Set Assessment (MDS, a federally mandated standardized assessment…

    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 before2026-02-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 25 residents sampled (Resident 83).Findings include: A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on March 19, 2025, revealed it is facility policy to maintain an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The policy indicates that diagnostic tests should be used wisely to avoid unnecessary antibiotic therapy or therapy that is unnecessarily broad-spectrum, with consideration to healthcare value. Bacterial cultures with susceptibility testing should be collected, handled, and processed promptly and appropriately to identify specific bacteria causing infection and facilitate the use of narrow-spectrum antibiotics whenever…

    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 · D2026-02-13 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, resident and staff interviews, and meal test tray results, it was determined the facility failed to serve meals that were palatable and at safe and appetizing temperatures for a test tray completed on the [NAME] Unit during the breakfast meal and for experiences of five of 25 residents sampled (Residents 82, 83, 20, 44, and 105).Findings included: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, specifies that food temperatures between 41 F and 135 F allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Hot foods must be maintained at or above 135 F and cold foods at or below 41 F. A review of a facility evaluation form titled Resident Tray Assessment revealed that hot food items were assessed based on being greater than or equal to 135 degrees Fahrenheit and on palatability. Palatable means acceptable to taste, including…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-09 · 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 clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to provide quality care as evidenced by the facility failure to ensure physician orders were followed for the administration of medication for one resident (Resident 61) and further failed to develop procedures and criteria for a palliative care program (Specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.) to provide person-centered care in accordance with the comprehensive person-centered care plan, and the residents' choices for palliative care for two of 28 sampled residents (Residents 14 and 39). Findings include: A review of facility policy titled: Preparing, Administering and Documenting Medications last reviewed by the facility on March 19, 2025, indicated that medications are administered within one…

    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 before2025-05-09 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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, select facility policy, and staff interviews, it was determined the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits for psychotropic medications for one of 28 residents (Resident 24). Findings include: A review of a facility policy titled Psychotropic Medication, last reviewed by the facility on March 19, 2025, revealed it is the facility policy that residents shall not receive psychotropic medications which are not clinically indicated to treat a specific condition. Further policy review revealed that documented consent, given voluntarily and free from coercion, by the resident or resident representative (if applicable), to use a psychotropic medication after being provided with sufficient information regarding general psychotropic use and specific considerations related to the psychotropic medication being considered for use will be obtained. A clinical record review revealed that Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 select facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders were consistent with a resident's documented code status (hospital designation that means to intercede if a patient's heart stops beating or if the patient stops breathing) preference for one of 28 residents reviewed (Resident 75). Findings include: A review of the facility's policy titled Cardiopulmonary Resuscitation, last reviewed on [DATE], indicated that when a resident's resuscitation preference is determined or changed, the facility is responsible for ensuring that the electronic medical record reflects the resident's choice in the Advanced Directives section and that physician orders match the resident's expressed wishes. A review of the clinical record of Resident 75, revealed the resident was admitted to the facility on [DATE], with diagnoses that included hypertension (blood pressure that is higher than normal) and epilepsy (a chronic brain disorder in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, observation, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 28 sampled (Resident 43). Findings include: A review of the facility policy titled Administration of Oxygen, last reviewed by the facility on March 19, 2025, revealed it is the facility's policy to provide oxygen therapy to residents upon order of the physician. The policy indicates it is the responsibility of the licensed nurse to initiate and monitor the administration of oxygen per physician's orders. A clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure with hypoxia (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Further clinical record review revealed Resident 43 had an altered respiratory status initiated…

    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 before2025-05-09 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, select facility policy review, and staff interview, it was determined the facility failed to reassess a resident's pain status and medication prescribed on as-needed (PRN) basis to ensure the development and implementation of an effective, individualized pain management plan for one of 28 residents sampled. (Resident 14). Findings include: A review of the facility's policy for pain assessment and management last reviewed, March 2025, revealed the facility will provide the resident with care and services to address and manage the resident's pain to support his or her highest practicable level of physical, mental, and psychosocial well-being. Using the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences, the resident will have pain identified and assessed, have the type of pain identified along with appropriate management approaches, and have pain adequately managed (eliminated if possible or relieved to a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2025-05-09 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of clinical records, observation, and staff interview it was determined the facility failed to provide a physician ordered therapeutic diet (diet ordered by a physician or other delegated provider that is part of tthe treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet, or to provide mechanically altered food when indicated) for one resident out of 28 sampled (Resident 54). Findings include: A review of the clinical record of Resident 54 revealed the resident had diagnoses which included Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) and oral phase dysphagia (difficulty swallowing which includes problems with using the mouth, lips, and tongue to control food or liquid). Review of a Speech Therapy Treatment Encounter Note dated May 14, 2024, revealed a recommendation for the use of lemon ice to facilitate oral movement for AP transfer [anterior-posterior transfer- the movement of the bolus (food or liquid mass) from the front of the mouth…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-16 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records, select resident incident report, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to thoroughly conduct and document the results of a professional nursing assessment regarding the clinical status of a resident following an elopement from the facility for one resident (Resident CR1) out of 4 residents reviewed. Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-16 · tag F0835 — failed to run the facility competently — isolated
    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 a review of observations, clinical records, investigate reports, staff interviews, and employee job descriptions it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to monitor resident whereabouts and prevent an elopement for one out of 4 sampled residents (Resident CR 1). Findings include: Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement by one resident (Resident CR 1) out of 4 sampled residents, placing the 6 residents out of 113 residents residing in the facility, identified at risk for elopement, in immediate jeopardy to their health and safety. A review of the clinical record of Resident CR1 revealed admission to the facility on May 14, 2024, with diagnoses, which included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), syncope…

    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 · Ecited before2024-07-19 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of opioid pain medications prescribed on an as needed basis for one resident out of 24 residents reviewed (Resident 10). Findings include: A review of Resident 10's clinical record revealed a physician's order, initially dated June 24, 2024, and discontinued on July 1, 2024, for Hydrocodone-Acetaminophen 5-325 mg (an opioid pain medication combined with a non-opioid pain reliever used to treat moderate to severe pain), give one tablet by mouth every 4 hours as needed for numeric pain scale 6-10. There was also a physician's order initially dated July 1, 2024, and discontinued July 3, 2024, for Hydrocodone-Acetaminophen 5-325 mg, give one tablet by mouth every 6 ours as needed for pain 6-10. A review of the resident's June 2024, Medication Administration Record (MAR) revealed that staff administered doses of the prn hydrocodone-acetaminophen pain medication 14 times during the month of June 2024. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-19 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to attempt a gradual dose reduction of psychoactive medications for one resident (Resident 44) and failed to clinically justify the increase of psychoactive medication for one resident (Resident 69) out of five sampled. Findings include: A review of Resident 44's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include schizoaffective disorder and Parkinson's disease. The resident had a physician order initially dated September 2023, for Invega Trinza Intramuscular Suspension Prefilled Syringe 819 MG/2.63 ML (Paliperidone Palmitate - an atypical antipsychotic drug) Inject 2.63 mg/ml intramuscularly one time a day every 90 days for schizoaffective disorder. The resident also had a physician order dated September 2023, for Sertraline HCL (an antidepressant drug, brand name Zoloft) Oral Tablet 50 MG 1 tab daily for depression and Abilify 10 mg (an antipsychotic drug) 1…

    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 before2024-07-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, a review of select facility policy, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The initial tour of the kitchen that was conducted with the facility's Director of Food and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · 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

    Based on review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician regarding a significant weight gain displayed by one resident out of 24 sampled (Resident 12). Findings include: A review of the clinical record revealed that Resident 12 was admitted into the facility on June 29, 2024, with diagnoses to include heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and the presence of a cardiac pacemaker (device implanted in our body to deliver electrical impulses to your heart to help your heartbeat at a normal rate and rhythm). The resident had a physician order dated June 29, 2024, for staff to obtain a daily weight, one time a day, related to heart failure. If the resident was noted to experience a 3-pound weight gain in 24 hours or a 5-pound weight gain in 1 week, the physician was to be notified. A review of the resident's weight record revealed that the resident weighed 181.2 pounds on June 29, 2024. On June…

    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 · D2024-07-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, it was determined that the facility failed to maintain a clean and sanitary environment for one resident out of 24 sampled (Resident 111). Findings include: A review of Resident 111's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included chronic pressure ulcers, dysphagia (difficulty swallowing) with use of a feeding tube [(enteral nutrition) uses a feeding tube to supply nutrients and fluids to the body when an individual cannot safely chew or swallow. Feeding tubes are soft, flexible plastic tubes through which liquid nutrition travels through the gastrointestinal (GI) tract] for primary means of nutrition and hydration. During observation of Resident 111's room on July 17, 2024, at 10:49 AM a pungent odor was detected. A plastic spoon and debris were observed underneath the resident's tube feeding pole. Dried tube feeding formula was observed splattered on the tube feeding pole and 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 · D2024-07-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, it was determined that the facility failed to timely develop and implement a person-centered care plan to meet one resident's current needs for the use of an implantable cardiac recording devices out of 24 sampled residents (Resident 69). Findings including: Clinical record review revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses anxiety, seizures, and stroke. Documentation in the clinical record revealed that on October 1, 2023, Resident 69 had an implantable loop recorder (a small device placed just under the skin of the chest during a minor surgery which records the heartbeat continuously for up to three years. Device requires a transmitter at bedside to automatically send information from recorder to the health care provider). A review of the resident's current plan of care, initially dated October 1, 2023, revealed that the resident's care plan did not identify the presence of, or the care, for the resident's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident timely received the necessary behavioral health care to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents sampled (Resident 53). Findings include: Review of clinical record of Resident 53 revealed that the resident was admitted to the facility on [DATE], with diagnoses including anxiety. Resident 53's clinical record review also revealed that the resident exhibited multiple behaviors, including constant yelling out help me, help me and arguing with the resident's roommate. Documentation in Resident 53's clinical record revealed that the resident displayed an increase in these behaviors beginning June 2024, according to a review of progress notes. Progress notes indicated that the resident was almost daily asking for help even while staff were present providing help. During July 2024, progress note documentation revealed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of clinical records and controlled drug records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications for one of 24 residents sampled (Resident 10). Finding include: A review of the clinical record revealed that Resident 10 had a physician order dated June 24, 2024, for Hydrocodone-Acetaminophen 5-325 mg (an opioid pain medication combined with a non-opioid pain reliever used to treat moderate to severe pain), give one tablet by mouth every 4 hours as needed for numeric pain scale 6-10 (pain scale, 1-10, 1 least pain, 10 most pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on June 28, 2024, at 4:15 PM, nursing staff signed out a dose of the resident's supply of Hydrocodone-Acetaminophen 5-325 mg. However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on that date and time. A physician order dated July 1, 2024, was noted for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 24 residents sampled (Residents 19). Findings included: Clinical record review revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses to include chronic kidney disease, kidney stones, and heart disease, and was followed by Nephrology for management of nephrostomy tube (a thin, flexible tube that drains urine from the kidney through an opening in the skin on the back) placed prior to admission to the facility. Review of clinical record revealed emergency room evaluation report dated May 22, 2024, which indicated that the resident required replacement of the nephrostomy tube due to dislodgement. Following review by infectious disease, antibiotic therapy was stopped as resident's urine culture had ESBL and VRE colonized bacteria (harmless presence of microorganisms). Review of clinical record…

    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 · Dcited before2024-05-14 · 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 clinical record review and staff interview, it was determined that the facility failed to provide prescribed treatment necessary to manage constipation and promote normal bowel activity to prevent related complications and demonstrate timely and thorough assessment of a resident for one resident out of seven sampled (Resident 1). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include stage 3 kidney disease, urinary retention, a history of constipation and fecal impaction and anxiety. An admission history and physical dated…

    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 before2023-08-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility guidelines and clinical records, and staff interview, it was determined that the facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for one of three residents reviewed (Resident A1). Findings include: Review of the facility Non-Invasive Pulse Oximetry Testing guidelines last reviewed by the facility February 2023 revealed that the practice of the facility is to perform non-invasive pulse oximetry test (quick and non-invasive monitoring technique that measure the oxygen level in the blood by shining light at specific wavelengths through tissue, most commonly the fingernail bed) to evaluate conditions which are commonly associated with oxygen desaturation (drops in oxygen level). Indications for pulse oximetry testing include: the resident exhibits signs or symptoms of acute respiratory dysfunction such as : tachypnea (abnormally rapid breathing); cyanosis (bluish discoloration of the skin from inadequate oxygen in the blood); confusion; severe chest pain; dyspnea (difficult…

    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
  • No harm found · B2026-02-13 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and resident and staff interviews, it was determined the facility failed to post the most recent survey results which include any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility and experiences reported by 5 out of 5 residents interviewed during a group interview (Residents 8, 44, 51, 55, and 105). Findings include: During a resident council interview on February 11, 2026, at 10:00 AM, five alert and oriented residents in attendance (Residents 8, 44, 51, 55, and 105) indicated they did not know where the facility posted the Department of Health survey results. Observation of the facility reception area on February 11, 2026, at 11:19 AM revealed there was state survey inspection results available in a binder in the lobby of the facility. Review of the binder revealed the most recent recertification results were not available in the binder. Recertification survey results from the survey of May 9, 2025, were not available. During an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-05-09 · 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 review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for five out of 28 residents reviewed (Residents 1, 20, 87, 90, and 18). Findings include: A review of the clinical record revealed that Resident 1 was transferred to the hospital on March 8, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 20 was transferred to the hospital on April 27, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 87 was transferred to the hospital on March 17, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 90 was transferred to the hospital on January 10, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record…

    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
  • No harm found · B2025-05-09 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's admission agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and resident representative, and the facility agree on the selection of a venue that is convenient to both parties. Findings include: A review of the facility's admission Agreement packet, specifically Section 19.4 Binding Arbitration Subsection (f) Location of Arbitration, contained Subject to mutual agreement of the parties, the arbitration will be conducted at the facility or at a site within a reasonable distance of the facility. During an interview on May 9, 2025, at approximately 10:30 AM, the Nursing Home Administrator (NHA) confirmed the language of the arbitration agreement does not state that the location of the arbitration will be at a venue that is convenient to both the resident/resident representative and the facility. The NHA confirmed the language of the policy states two options for the location of arbitration (1) at the facility or (2) a site within a reasonable distance…

    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 · B2024-07-19 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and transfer notices, and staff interviews, it was determined that the facility failed to provide written notices of facility-initiated transfers to the resident and the resident's representative for one out of the 24 residents reviewed (Residents 69). Findings include: A review of the clinical record of Resident 69 revealed the resident was transferred to the hospital on May 29, 2024, and readmitted to the facility on [DATE]. There was no documented evidence that the facility provided the resident and the resident's representative written notice of the transfer Interview with the Nursing Home Administrator and Assistant Director of Nursing on July 18, 2024, at approximately 11:30 AM, confirmed that the facility had no documented evidence that Resident 69 and the resident's representative were provided written notice of this facility-initiated transfer to the hospital. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

    Resident Rights 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

$8,021 in federal fines across 1 penalty.

  • $8,021 — penalty dated 2024-07-19

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 UNITED METHODIST HOMES — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:

RatingThis homeChain avg
Overall 3 of 52.5+0.5 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 4 of 53.5+0.5 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 1 home this chain runs (chain average 2.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
AUGUSTINE, EMILIndividualCORPORATE DIRECTORsince 05/31/2017
BETZ, EDWINIndividualCORPORATE DIRECTORsince 05/28/2003
BYRNE COLLING, KATHLEENIndividualCORPORATE DIRECTORsince 08/27/2014
DIRHAN, COLEMANIndividualCORPORATE DIRECTORsince 01/01/2024
GRILLINI, CATHERINEIndividualCORPORATE DIRECTORsince 01/01/2024
HERTEL, ALANIndividualCORPORATE DIRECTORsince 01/29/2020
HORN, JANICEIndividualCORPORATE DIRECTORsince 01/01/2024
JOHNSON, MARYANNIndividualCORPORATE DIRECTORsince 05/25/2011
KINSMAN, ALLANIndividualCORPORATE DIRECTORsince 05/23/2002
LAMANTIA, SALVATOREIndividualCORPORATE DIRECTORsince 10/03/2017
LEE, LISAIndividualCORPORATE DIRECTORsince 05/26/2016
LEWIS, SHARRONIndividualCORPORATE DIRECTORsince 08/31/2016
LEWIS, WILLIAMIndividualCORPORATE DIRECTORsince 01/01/2024
MULLIGAN, ROSEANNEIndividualCORPORATE DIRECTORsince 08/27/2014
OLAVIANY, TANYAIndividualCORPORATE DIRECTORsince 01/01/2024
RAY, MARGARETIndividualCORPORATE DIRECTORsince 08/29/2018
REID, PHILIPIndividualCORPORATE DIRECTORsince 05/26/2016
SMITH, BLENDAIndividualCORPORATE DIRECTORsince 11/19/2014
STARR, WILLIAMIndividualCORPORATE DIRECTORsince 05/31/2017
TESTA, KENDRAIndividualCORPORATE DIRECTORsince 01/01/2024
THOMAS, CHARLOTTEIndividualCORPORATE DIRECTORsince 05/30/2018
BALWIERCZAK, MORGANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/01/2025
PICCHINI, BRIANIndividualCORPORATE OFFICERsince 01/01/2012
UMH PA CORPOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/23/2007
VALENTI, SAMUELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/26/2026
YASHINSKY, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 29 rows in the source record cover these 26 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$19.8M
Net patient revenuemost recent cost report
-30.4%
Operating marginrevenue minus expenses
$1.7M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 12%Other / private 24%

This home reported $1.7M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$571per resident / day
operating cost
$17,362per month
≈ monthly operating cost
$438per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

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 395602. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-13, 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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