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Belle Terrace

1320 Mill Road, Quakertown, PA 18951 · For profit - Limited Liability company · 59 certified beds · (215) 536-7666 Medicare & Medicaid certified

Call the home — (215) 536-7666 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Jan 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (71%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 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
St. Luke's Wound Management-Quakertown, 1021 Park Ave · (484) 526-5585 · Call to confirm hours
Pharmacy
Rite Aid0.5 mi
1465-15 W Broad St · (215) 536-7651 · Call to confirm hours
Grocery
1465 W Broad St · (215) 538-3399 · Call to confirm hours
Park
670 S Main St · (267) 490-4808 · 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 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased10.3%16.8%15.4%better
Long-stay residents who lose too much weight7.4%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.7%0.9%typical
Long-stay residents with a urinary tract infection0.6%1.5%2.0%better
Long-stay residents with depressive symptoms33.1%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 injury5.0%3.1%3.3%worse
Long-stay residents whose ability to walk worsened9.7%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.3%20.0%18.9%worse
Long-stay residents given the seasonal flu vaccine84.0%93.5%95.3%worse
Long-stay residents with pressure ulcers1.3%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control32.1%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table26.4%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.8%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine33.7%68.7%79.4%worse
Short-stay residents rehospitalized after admission29.6%22.5%22.6%worse
Short-stay residents with an outpatient ER visit16.5%9.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.061.621.67worse
Long-stay outpatient ER visits per 1,000 resident days1.421.181.80better

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.

40.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.8%U.S. median 51.5%
Got home and stayed home
13.6%U.S. median 10.7%
Went back to hospital
64.2%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 64.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 53 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF40.8%CMS range 34.4–48.051.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.6%CMS range 9.8–17.510.7%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 discharge64.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge49.1%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 discharge39.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.4%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 worsened1.2%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 hospitalization7.4%CMS range 4.1–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 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

0.58
RN hours/ resident / day
0.75
LPN hours/ resident / day
1.79
Aide hours/ resident / day
3.11
Total nurse hours/ resident / day
0.47
RN hoursweekends
71.2%
Total nursing turnover
75.0%
RN turnover

How full it usually is: this home is certified for 59 beds and averages 53.3 residents a day — about 90% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.94 hrs/resident/day on weekends vs 3.18 on weekdays — 8% thinner on weekends. RN hours go from 0.62 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 71% is well above 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 (2025-12-05)
9
at the previous standard inspection (2025-01-16)

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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-17 · 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 — the official record, unedited, may be distressing

    Based observations and staff interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of two nursing units. (Unit B)Findings include: Observations on June 17, 2026, at 10:30 a.m., and 1:45 p.m., revealed that the grab bars on the left side of the toilets in the bathrooms of rooms B 48 and B 52 were loose. In an interview on June17, 2026, at 2:30 p.m., the Administrator confirmed the grab bars in the bathrooms in rooms B 48 and B 52 needed to be repaired. 28 Pa. Code 207.2(a) Administrator's responsibility.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to maintain the environment in a clean, comfortable, and homelike manner on two of two nursing units. (A and B wing)Findings include: Observations on December 3, 2025, from 10:45 a.m. through 2:00 p.m., and on December 4, 2025, from 10:45 a.m. through 2:00 p.m., revealed the following environmental issues: In the shower room on A wing, the first room to the right of the door had a sink with brown stains and the faucet had white stains on it. The toilet had a black ring inside. In the shower room's central shower area, there were open holes in the wall around the shower valve system where the water flow and temperature were controlled. The bathtub room to the left of the central hallway had a marred wall on the left back side of the room, the bathtub had blue and brown stains inside, around the drain, and on the side wall by the faucet. The bathtub faucet had white stains. The shower stall in the back of the shower room had a brown ring around 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 · D2025-12-05 · 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

    Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 14 sampled residents. (Resident 19) Findings include: Review of the facility policy entitled, Self-Administration of Medications, last reviewed on November 20, 2025, revealed that residents had the right to self-administer medications if the staff and practitioner determined it was clinically appropriate for residents to do so. Clinical record review revealed that Resident 19 had diagnoses that included chronic obstructive pulmonary disease (COPD) and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated October 10, 2025, revealed that the resident's cognitive ability was intact and that he used oxygen. On October 31, 2025, a consulting specialist physician recommended that Resident 19 start taking an inhaler medication to treat COPD daily and that the patient must have this inhaler in his room to be taken immediately upon awakening. 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 · D2025-12-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, 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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of two of 14 sampled residents. (Residents 1 and 4) Findings include: Clinical record review revealed that Section C (Brief Interview for Mental Status) of Resident 1's MDS assessment dated [DATE], was incomplete. In an interview on December 3, 2025, at 9:00 a.m., the Administrator confirmed that Resident 1's MDS assessment was incomplete. Clinical record review revealed that Resident 4 received hospice services starting on November 13, 2025. The MDS assessment dated [DATE], incorrectly indicated in Section O (Special treatments, Procedures, Programs) that the resident was not receiving hospice services during the previous seven days. In an interview on December 3, 2025, at 9:59 a.m., the Director of Nursing confirmed that Resident 4's MDS assessment was inaccurate.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 14 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included depression. According to the Minimum Data Set Care Area Assessment summary dated January 22, 2025, the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration record from January through December 2025, revealed the resident received an antidepressant (trazodone) during the review period. There was no documented evidence that interventions to address Resident 1's psychotropic drug use were included in the current care plan. In an interview on December 5, 2025, at 10:00 a.m., the Director of Nursing confirmed there was no documented evidence that the care area was addressed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-05 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, observation, and staff and resident interviews, it was determined that the facility failed to accommodate food preferences for one of 14 sampled residents. (Resident 54)Findings include:Review of the facility's weekly menu revealed that the lunch meal for December 3, 2025, was spaghetti noodles with meat, breadstick, tossed salad, and fruit cocktail. Clinical record review revealed that Resident 54 had diagnoses that included anxiety, gastroesophageal reflux disease, and major depressive disorder. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and able to make her needs known. During an interview on December 3, 2025, at 12:25 p.m., Resident 54 stated that her meals did not match what was on her ticket and she received foods she did not like. On December 3, 2025, at 12:30 p.m., her lunch tray was observed on her bedside table and had spaghetti noodles and meat sauce. Resident 54 stated that she did not…

    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 before2025-12-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and use of personal protective equipment (PPE) to prevent the spread of infection for one of four sampled residents observed during medication administration. (Resident 4)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed on November 20, 2025, revealed that staff was to wear a gown and gloves during high contact resident care activities, such as using the resident's feeding tube and for residents with indwelling medical devices to minimize the spread of multidrug resistant organisms. Clinical record review revealed that Resident 4 had diagnoses that included dysphagia (difficulty swallowing) and lung cancer. Review of the Minimum Data Set (MDS) assessment, dated November 18, 2025, revealed that Resident 4 had an enteral feeding tube (a soft plastic tube inserted into the digestive system used to provide nutrition directly through the stomach.) On November 3,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-23 · 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, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure, atrial fibrillation (irregular rapid heart rhythm that can lead to bloods clots or a stroke), muscle weakness and angiodysplasia of the stomach and duodenum (an abnormality characterized by dilated, fragile blood vessels). The Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was alert and had pulmonary hypertension (high blood pressure that affects the arteries in the lungs). On April 3, 2025, there was a physician's order that directed staff to schedule a chest X-ray for Resident 1 related to pleural effusion hypoxia (excessive fluid build-up in the lungs), and a physician's order dated April 7, 2025, that directed staff to obtain a stool specimen to rule out…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · 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 clinical record review, observation, and interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for three of eight sampled residents. (Residents 1, 2, 3). Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure, atrial fibrillation (irregular rapid heart rhythm that can lead to bloods clots or a stroke), muscle weakness, pulmonary hypertension (high blood pressure that affects the arteries in the lungs), and angiodysplasia of stomach and duodenum (an abnormality characterized by dilated, fragile blood vessels). According to the Minimum Data Set (MDS) assessment, dated March 19, 2025, the resident was at risk for pressure ulcers, had limited mobility of her lower legs, and could communicate her needs. On March 12, 2025, a physician's order directed staff to apply heel boots (devices to protect the skin of the feet) while in bed. Review of the comprehensive care plan revealed that the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, employee file review, and staff interview, it was determined that the facility failed to initiate an employee criminal background check, verify professional license/registration, and/or ensure employees completed required abuse training in a timely manner for six of six newly hired employees. (Employees RN 1, RN 2, RN 3, NA 1, NA 2, DA 1) Findings include: Review of the facility policy entitled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, last reviewed October 10, 2024, revealed that the facility was to screen potential employees for a history of abuse, neglect, or mistreating residents prior to employment. This included attempts to obtain information from previous employers and checking with the appropriate licensing boards and registries. The facility was also to educate staff upon hire and annually thereafter regarding the facility's policy to prevent Abuse, Neglect, and Exploitation of residents, and Misappropriation of Resident Property. Review of employee files revealed the following: NA 1 had been…

    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
Show the remaining 16 citations
  • Potential for harm · D2025-01-16 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted dignity for one of 16 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included dysphagia, dementia, and need for assistance with personal care. Review of the care plan revealed that the resident had neurological deficiencies and a history of weight loss. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment. Observation of lunch on January 15, 2025, from 12:25 p.m., through 12:45 p.m., revealed that Resident 5 was sitting at a table with the meal tray on the table with more than 75% of the meal uneaten. There was food on the resident's sweater. The resident proceeded to bite at and lick the food on her sweater. The resident did not obtain utensils or food from her tray and continued to chew and suck on her sweater for the remainder 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to report an allegation of abuse to the Administrator and the State Survey Agency for one of 16 sampled residents. (Resident 16) Findings include: Review of the facility policy entitled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, last reviewed October 10, 2024, revealed that all incident and allegations of abuse were to be reported immediately to the administrator or designee. Clinical record review revealed that Resident 41 had diagnoses that included anxiety, cognitive decline, and Alzheimer's disease. On October 12, 2024, staff noted that in the morning during the day (7:00 p.m. to 3:00 p.m.) shift, that Resident 41 put a brief over Resident 16's head. Resident 41 started punching Resident 16 and stated she was going to smash her in the face with a heavy object. Resident 41 also stated that she wanted to kill Resident 16 multiple times throughout the shift. There was no evidence that staff notified…

    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 · Dcited before2025-01-16 · 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

    Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 16 sampled residents. (Resident 40) Findings include: Clinical record review revealed that Resident 40 had diagnoses that included heart failure and reduced mobility. According to the Minimum Data Set assessment, dated November 23, 2024, the resident was at risk for pressure ulcers, had limited mobility of her lower legs, and could communicate her needs. On March 12, 2024, the physician ordered that staff float heels (elevate the lower leg so the heel doesn't touch the bed) while in bed. On January 14, 2025, at 11:32 a.m., Resident 40 was observed with her heels directly on the bed. That same day at 1:55 p.m., the resident stated that staff had not been floating her heels, and she was observed with her heels directly on the bed. The resident was again observed on January 15, 2025, at 9:54 a.m., with her heels directly on the bed. CFR 483.25 Quality of care Previously cited 12/28/23, 8/10/24 28 Pa. Code 211.12…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and family and staff interview, it was determined that the facility failed to provide ostomy (an opening of the bowel through the abdomen), care in accordance with the resident's care plan for one of one sampled resident who had an ostomy. (Resident 158) Findings include: Review of a facility policy entitled, Colostomy/Ileostomy Care, last reviewed October 10, 2024, revealed that staff were to document the date and time the ostomy care was provided, as well as, the name and title of the person who provided the care in the resident's medical record. Clinical record review revealed that Resident 158 was admitted to the facility on [DATE], and had a diagnoses that included Dementia. Review of the care plan revealed that the resident had an ileostomy. The interventions were for staff to keep the skin around the stoma clean and dry, monitor the skin for irritation, and observe the stoma for unusual changes. In an interview on January 14, 2025, at 12:35 p.m., the resident's family…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were reviewed by the physician in a timely manner for one of 16 sampled residents. (Resident 41) Findings include: Clinical record review revealed that Resident 41 had diagnoses that included anxiety and Alzheimer's disease. Review of a pharmacist's recommendation dated August 1, 2024, revealed that the pharmacist noted that the resident was prescribed melatonin and trazodone at hour of sleep (HS). The pharmacist recommended that the physician review the need for both medications and determine if the melatonin could be discontinued to reduce the resident's amount of medication. There was no evidence that the physician addressed the pharmacist's recommendations until October 1, 2024, or that the melatonin was discontinued until October 2, 2024. In an interview on January 16, 2025, at 12:37 p.m., the Director of Nursing stated that pharmacy recommendations should be addressed by the physician within five to seven days and there was no evidence that…

    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 · D2025-01-16 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of facility documents and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarterly meetings, the first and fourth, of 2024. Findings include: Review of the facility ' s Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records for meetings held in the first quarter of 2024 revealed the facility's Medical Director failed to attend. Review of facility ' s monthly Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records for meetings held in the fourth quarter of 2024 revealed the facility's Medical Director failed to attend. In an interview on January 16, 2025, at 11:39 a.m., the Administrator confirmed that the Medical Director did not attend all of the quarterly meetings. 28 Pa Code: 201.18(e)(1)(2)(3) Management.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for two of 16 sampled residents. (Residents 27 and 35) Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed October 10, 2024, revealed that enhanced barrier precautions were to be used with any resident with a wound or medical device during encounters when contact is expected, including during wound care and the care of feeding tubes. Precautions included the use of protective gowns during the high risk activities. Clinical record review revealed that Resident 27 had diagnoses that included a Stage 3 pressure sore on his lower back. On January 15, 2025, at 9:06 a.m., a physician (MD 1) was observed entering Resident 27's room to examine his pressure sore. MD 1 did not use a protective gown in accordance with facility policy. Clinical record review revealed that Resident 35 had diagnoses that included a history of stroke with difficulty swallowing. She…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-10 · 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

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of four sampled residents. (Residents 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included intervertebral disc displacement (when a disc in the spinal column shifts and presses on against the spinal nerves) and morbid obesity. A physician's order dated July 2, 2024, directed staff to cleanse surgical incision to lower back with normal saline solution and pat dry, to keep incision clean and dry, to keep the incision open to air, and to apply folded abdominal pad dressing (ABD) on each side of the incision due to skin fold two times a day. A review of the July 2024 Treatment Administration Records (TARs) revealed that there was no evidence the treatment was done as ordered on July 3, 4, and 6, 2024. Clinical record review revealed that Resident 2 had diagnoses that included metabolic encephalopathy and cellulitis of bilateral lower extremities. A review of physician's orders 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 · F2024-08-01 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on policy review and staff interview, it was determined that the facility did not have a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control. Findings include: Review of the facility policy entitled, Infection Prevention and Control Plan, last reviewed March 28, 2024, revealed that the IP was to provide oversight for the infection prevention and control program, conduct surveillance of any facility and community associated infections, and serve as a resource to all staff regarding infection prevention and control. In an interview on August 1, 2024, at 1:15 p.m., the Administrator stated the facility did not have a qualified Infection Preventionist. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-01 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on two of two nursing unit wings. (A Wing, B Wing) Findings include: Review of the facility policy entitled, Transmission Based Precautions, last reviewed March 28, 2024, revealed that transmission based precautions (TBPs) may include contact precautions, droplet precautions, airborne precautions, and enhanced barrier precautions that vary with how restrictive they are in requiring certain personal protective equipment (PPE). If a resident is identified as having a communicable disease, then TBPs are to be initiated. Staff were to post a sign on the door that all personnel and visitors entering the room must first see the nurse to obtain additional information before entering the room as part of maintaining the specific TBP and PPE protocol. Review of the facility policy entitled, COVID-19, last reviewed March 28, 2024, revealed that droplet precautions were to be implemented 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-28 · 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 clinical record review and staff interview, it was determined that the facility failed to develop a care plan and interventions to meet each resident's needs as identified in the comprehensive assessment for two of 13 sampled residents. (Residents 25, 154) Findings include: Clinical record review revealed that Resident 25 had diagnoses that included chronic obstructive pulmonary disease and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the Care Area Assessment (CAA) summary triggered urinary incontinence and dental care as problem areas to be care planned. Resident 25's current care plan did not include interventions to address urinary incontinence and dental care. Clinical record review revealed that Resident 154 had diagnoses that included displaced left femur fracture, muscle weakness, and chronic obstructive pulmonary disease. Review of the MDS assessment dated [DATE], revealed that the CAA summary triggered pain and urinary incontinence as…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-28 · 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

    Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that physicians' orders or care plan interventions were implemented for two of 13 sampled residents. (Residents 36, 42) Findings include: Review of the facility policy entitled, Weight Assessment and Intervention, last reviewed January 1, 2023, revealed that staff was to weigh each resident monthly after the first two weeks following admission. Clinical record review revealed that Resident 36 had diagnoses that included depression, anxiety, and morbid obesity. A physician's order dated November 24, 2021, directed staff to observe the resident and document for side effects of antidepressants including weight gain. Review of the current care plan revealed, Resident 36 was at risk for altered nutrition with an intervention for staff to weigh and monitor the resident's weight per facility policy. There was no documentation that staff weighed Resident 36 in September, November, and December 2023. Clinical record review revealed that Resident 42 had diagnoses that…

    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 before2023-12-28 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on policy review, observation, and staff interview, it was determined that the facility failed to administer medications in accordance with facility infection control policies on one of two nursing units. (A hall) Findings include: Review of the facility policy entitled, Administering Medication, last reviewed January 1, 2023, revealed that staff was to follow established facility infection control procedures for the administration of medications including hand hygiene. On December 27, 2023, LPN 1 was observed administering medications to Resident 49. The nurse touched each pill with her ungloved hand prior to administering them to the resident. In an interview on December 28, 2023, at 10:00 a.m., the Director of Nursing stated that nurses may not touch medications with their hands unless they are wearing clean gloves. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, review of facility documentation, and interview, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on the nursing unit. Findings include: Observation of the kitchen on November 6, 2023, at 9:41 a.m., revealed a white substance on the shelves in the walk-in refrigerator. There was a black substance and particles of debris on the floor of the same refrigerator. There were two opened packages of cheese with open dates of September 2, 2023, and October 15, 2023. There were no use-by dates on the packages. In an interview at the time, the Director of Dining Services stated that the opened packages should be used or discarded within seven days. There was a bucket of thickener and the measuring cup used to scoop the product was stored directly on top of the lid. There were numerous saturated towels under the three compartment sink. In an interview, the Director of Dining Services stated that the towels had been there since the previous day. There was an dust on the shelves that stored clean pots and pans. There was 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-01-16 · 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 — 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 notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for three of three sampled residents who were transferred to the hospital. (Resident 11, 13, 56) Findings include: Clinical record review revealed that Resident 11 was transferred to the hospital on October 12, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 13 was transferred to the hospital on December 11, 2024, after a fall and change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 56 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
  • No harm found · Bcited before2024-03-14 · 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a clean, homelike, and comfortable environment on two of two nursing units. (A-wing and B-wing) Findings include: During tours of A-wing and B-wing nursing units on March 14, 2024, between 10:12 a.m. and 11:30 a.m., the following were observed: In rooms 27, 32, 36, and 47, there were holes in the partition wall between the residents' sleeping area and the bathroom On the right side of the B-wing hallway, between rooms [ROOM NUMBERS], there was detached molding in the space where the floor met the wall, exposing a large hole in the wall. In the shared bathroom located between rooms [ROOM NUMBERS], two round holes in the sheetrock were observed. In room [ROOM NUMBER]-2, there was a hole in the wall under the window. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to MORDECHAI WEISZ — 7 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 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 2 of 51.7+0.3 vs chain
Quality measures 3 of 54.4-1.4 vs chain
The other 6 homes this chain runs (chain average 2.4★, 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
METROPOLITAN COMMERCIAL BANKOrganization5% OR GREATER MORTGAGE INTERESTsince 02/15/2022
FENSTERHEIM, AVROHOMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/07/2024
MCBREARTY HINDSON, ASHLEYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/07/2024
OAKWOOD MANAGEMENT GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/07/2024
WEISZ, MORDECHAIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/07/2024
ML FAMILY TREE TRUSTOrganizationADP OF THE SNFsince 02/15/2022
ML KIDS HOLDINGS LLCOrganizationADP OF THE SNFsince 02/15/2022
UB LLCOrganizationADP OF THE SNFsince 08/12/2025

CMS files one row per role, so the 14 rows in the source record cover these 8 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.

$7.4M
Net patient revenuemost recent cost report
+10.3%
Operating marginrevenue minus expenses
$611K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 17%Other / private 16%

This home reported $611K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$352per resident / day
operating cost
$10,714per month
≈ monthly operating cost
$393per 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 395574. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, 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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