Elan Skilled Nursing And Rehab, A Jewish Senior Li
1101 Vine Street, Scranton, PA 18510 · Non profit - Corporation · 145 certified beds · (570) 344-6177 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,418 in federal fines (most recent 2025-11-21)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.8% | 16.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.7% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.0% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.5% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.4% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.7% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.7% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.2% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 26.0% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.8% | 17.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.6% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.4% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.9% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 1.62 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.30 | 1.18 | 1.80 | better |
§ 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.
51.9% 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 201 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 168 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 51.9%CMS range 43.9–58.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 6.5–12.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 42.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 3.7–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.75 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 145 beds and averages 133.0 residents a day — about 92% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.47 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.99 hrs/resident/day on weekends vs 4.66 on weekdays — 14% thinner on weekends. RN hours go from 0.68 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Ldisputed · IDR2026-01-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 select facility policy, and staff interviews, it was determined the facility failed to ensure the kitchen was maintained in a manner that ensured food was prepared, distributed, and served under sanitary conditions and free of pest infestation. The presence of live and dead cockroaches in food preparation and storage areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms. This failure created an increased potential for foodborne illness and placed 135 of 135 residents in a situation of Immediate Jeopardy to their health and safety.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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2026-06-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, facility investigative documentation, and staff and resident interviews, it was determined the facility failed to implement adequate accident prevention measures when staff transported a resident identified as being at risk for falls through the hallway in a shower chair, for one out of 8 residents sampled (Resident 1) resulting in actual harm including a frontal scalp hematoma. This deficiency is cited as past noncompliance. Findings include: A review of the facility policy titled Personal Hygiene, last reviewed by the facility in June 2026, revealed it is the facility's policy that residents should not be transported to the shower room in the shower chair. A review of a medical guideline titled Falls and Fall Prevention in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline developed by the Post-Acute and Long-Term Care Medical Association (PALTmed) and published February 2, 2026 revealed that In the PALTC setting, patients taking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited beforedisputed · IDR2026-01-23 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 facility policy, facility-provided documentation, and interviews with residents and staff, it was determined the facility failed to maintain an effective pest control program to ensure the facility was free of pests, and rodents on two out of four resident nursing units (Nursing Units 3 and 4) and in the kitchen of the facility.Findings include: According to the Centers for Disease Control (CDC), in Controlling Wild Rodent Infestations, rodents can carry many diseases that can spread directly or indirectly to people, including through contact with rodent droppings, urine, or saliva. Signs of rodents include droppings (feces) and gnaw marks. The CDC indicates that to determine if the activity is current, regular cleaning and disinfecting are required. When droppings are identified following cleaning, it can confirm the presence of rodents. A review of the facility policy titled Preventative Maintenance Program, last reviewed by the facility on December 11, 2025, revealed it is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-11-21 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 facility policy, facility-provided documentation, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of insects, pests, and rodents on two out of four resident nursing units (Nursing Units 3 and 5).Findings include: According to the Centers for Disease Control (CDC), in Controlling Wild Rodent Infestations, rodents can carry many diseases that can spread directly or indirectly to people, including through contact with rodent droppings, urine, or saliva. Signs of rodents include droppings (feces) and gnaw marks. The CDC indicates that to determine if the activity is current, regular cleaning and disinfecting are required. When droppings are identified following cleaning, it can confirm the presence of rodents. A review of the facility policy titled Pest Control, last reviewed by the facility on January 20, 2025, revealed that it is the facility policy to maintain 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.
- Potential for harm · E2025-11-21 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set for three of 30 residents sampled (Resident 11, 43, and 133).Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS,a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2025, requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A clinical records review revealed Resident 11 was admitted to the facility on [DATE] with diagnoses including Borderline Personality Disorder (a serious mental illness that involves…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-21 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included individualized interventions for maintaining skin integrity for two out of 30 residents sampled (Residents 4 and 42).Findings include: A review of the facility policy titled Comprehensive Person-Centered Care Planning Comprehensive Care Plan Policy, last reviewed by the facility on January 20, 2025, revealed it is the facility's policy that the completion and implementation of a comprehensive person-centered care plan is intended to address the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. The Comprehensive Care Plan will be reviewed after each assessment as required by Federal and/or State Regulations and will be revised based on the resident's changing goals, preferences, and needs and in response to current interventions. A clinical record review revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-21 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication according to the provider's parameters for two out of 30 sampled residents (Resident 125 & Resident 72). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to 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 function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 the facility failed to demonstrate that a resident's discharge from the facility was appropriate and necessary for one of 30 sampled residents (Resident 94).Findings include:A review of the clinical record revealed Resident 94 was admitted to the facility on [DATE], with diagnoses that included diverticulosis of the large intestine without perforation or abscess without bleeding (presence of one or more balloon-like sacs in the colon) and generalized anxiety disorder (a disorder characterized by excessive worry that interferes with daily functioning). Review of the admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 31, 2025, revealed that Resident 94 had a Brief Interview for Mental Status (BIMS), a cognitive assessment tool used in long-term care settings to evaluate cognitive function within the Cognitive Section of the MDS, with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policies, professional guidelines, staff interviews, resident observation (including wound observation) and staff interview, and documentation review, it was determined the facility failed to implement appropriate interventions consistent with professional standards of practice to prevent the development and worsening of a pressure injury for one resident (Resident 44) and further failed to conduct timely and thorough assessment of a pressure sore and initiate timely treatment to promote healing and prevent worsening of an existing pressure sore for one resident (Resident 77) of 30 residents reviewed.Findings include: According to the National Pressure Injury Advisory Panel (NPUAP) (2025, September) a pressure injury is localized damage to the skin and underlying soft tissue. The skin injury occurs due to intense and/ or prolonged pressure or pressure in combination with shear. The NPUAP (2025) further writes that the heel is among the most common sites on the body…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis and failed to ensure the physician orders were followed for one resident (Resident 136) of 30 residents reviewed. Findings include: A review of the facility policy, titled Pain Management last reviewed on January 20, 2025, indicated that in an effort to help a resident attain or maintain the highest practicable level of well-being and to manage pain, the facility, to the extent possible will recognize when the resident is experiencing pain and identify circumstances when pain can be anticipated; evaluate the existing pain and the cause(s); and manage pain consistent with the comprehensive assessment and plan of care, current clinical standards of practice and the resident's goals and preferences. The policy further revealed pain documentation will include both…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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, facility provided investigative documentation, and staff interview, it was determined the facility failed to implement an effective, individualized, person centered care plan to address a resident's dementia related combative behavior for one of three residents reviewed (Resident 91).Findings include: A review of the clinical record revealed that Resident 91 was admitted to the facility on [DATE], with diagnoses including dementia (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) and anxiety (a mental health condition characterized by persistent worry or fear that interferes with daily functioning). A significant change Minimum Data Set (MDS an assessment completed periodically to plan resident care) dated August 11, 2025, indicated that Resident 91 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and the ability 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.
- Potential for harm · D2025-11-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident clinical records, select facility policy, staff, and staff interview, it was determined the facility failed to ensure that one of the 30 residents sampled was free of a significant medication error (Resident 94).Findings include:A review of the clinical record revealed Resident 94 was admitted to the facility on [DATE], with a diagnosis of diverticulosis of large intestine without perforation or abscess without bleeding (presence of one or more balloon-like sacs in the colon) and generalized anxiety disorder (a condition characterized by excessive worry and worry that interferes with daily functioning). A review of the admission, comprehensive Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care)) revealed that Resident 94 had a Brief Interview for Mental Status (BIMS, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new…
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.
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- Potential for harm · D2025-11-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to accommodate resident food allergies or intolerances for one of 30 sampled residents (Resident 82). Findings include: A review of the facility policy titled Departmental Food Service Policies- Gluten-Free/Restricted Diet, last reviewed by the facility on January 20, 2025, revealed the purpose of the policy was to promote healing of the small intestine and allow normal nutrient digestion and absorption. To decrease symptoms caused by sensitivity to gluten and gluten-containing products, such as classic symptoms of distention, flatulence, diarrhea, steatorrhea, and weight loss, and atypical symptoms such as growth retardation, chronic fatigue, pain, and anemia. The policy indicated that the guidelines for individuals with gluten-related disorders (celiac disease or non-celiac gluten sensitivity) stated that they must avoid gluten for health reasons. Gluten is the generic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, and staff interviews, it was determined that the facility did not follow physician-ordered diagnostic evaluation for suspected scabies for one resident (Resident 75), to possibly prevent and mitigate the spread of scabies in the facility and that an additional resident of 30 residents sampled (Resident 52) was identified with scabies on microscopic exam resulting in multiple residents in the facility being treatment for exposure, creating a potential for transmission among residents on impacted units.Findings include: A review of the facility policy entitled Scabies Information, Treatment, and Environmental Cleaning, last reviewed on October 7, 2025, indicated it is the policy of the facility to treat residents infected with and sensitized to Sarcoptes scabiei (scabies) and to prevent the spread of scabies to other residents and staff. Scabies is an itching irritation caused by the microscopic human itch mite, which burrows into the skin's layers and eventually…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0949 — failed to train staff on dementia and abuse — isolatedProvide behavior health training consistent with the requirements and as determined by a facility assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, facility provided investigative information, facility education records, and staff interview it was determined that the facility failed to provide dementia and behavior related training to one employee out of two employee education records reviewed (Agency Employee 12). Findings include: A review of the facility Dementia Programming Policy (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) last reviewed by the facility on January 20, 2025, revealed the facility will provide a comprehensive dementia program to the residents, staff, and families which include caregiving strategies, ongoing education, and support families in a collaborative approach to care for residents with dementia. A review of Employee 12's (agency nurse aide) Agency Personnel Orientation checklist, with a documented start date of September 20, 2025, revealed no evidence that the facility provided the required training on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-24 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of clinical records and staff interview it was determined the facility failed to provide residents or their representatives with written information of the facility's bed hold policy upon transfer to the hospital of three residents out of 27 residents sampled (Residents 27, 124, and 102). Findings include: A review of Resident 27's clinical record revealed the resident was transferred to the hospital on November 27, 2024, and returned to the facility on December 3, 2024. A review of Resident 124's clinical record revealed the resident was transferred to the hospital on November 26, 2024, and returned to the facility on November 29, 2024. A review of Resident 102's clinical record revealed the resident was transferred to the hospital on December 10, 2024, and returned to the facility on December 13, 2024. There was no documented evidence the facility provided these residents and/or their representatives written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) at the time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-24 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 the facility failed to follow physician orders for medication administration for three resident out of 27 sampled (Resident 121, 124, and 46). Findings include: 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 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 function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-24 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the consultant pharmacist failed to identify drug irregularities (dual anti-depressant therapy and justification for antipsychotic medication) when completing monthly medication reviews and the facility failed to assure that resident's attending physician timely acted upon pharmacist identified irregularities in the medication regimen for two residents out of five residents sampled for unnecessary medications (Residents 114 and 130). Findings included: Review of Resident 114's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia with behavioral disturbances (is a general term that describes the deterioration of memory, language, and other thinking abilities and can be accompanied by behavioral and psychological symptoms such as agitation, anxiety, and psychosis) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest 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.
- Potential for harm · D2025-01-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interviews it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment on one of four resident care units (5th floor). Findings include: An observation on January 23, 2024, at approximately 9:40 AM revealed in a Broda chair in the hallway outside room [ROOM NUMBER] revealed the following: The seat of the chair was heavily soiled with a crusty orange substance. The footrest was heavily soiled with a dried white and brown substance. The rear wheels were heavily soiled with dirt and debris with a significant amount of hair entangled in the base. Further observation of room [ROOM NUMBER] revealed a fall mat on the floor beside the resident's bed (nearest the door). The mat had large tears at its folding point and on the front corner, exposing the internal foam. Interview with Employee 1, licensed practical nurse, on January 23, 2024, at approximately 9:50 AM, confirmed the observations. Interview with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility's abuse policy, clinical records, and select investigative reports and staff interview it was determined the facility failed to assure that one resident (Resident 289) was free from sexual abuse perpetrated by another resident (Resident 102) and one resident (Resident 25) was free from neglect out of 27 residents sampled. Findings included: A review of the current facility policy titled Abuse Prohibition, last reviewed by the facility on September 6, 2024, revealed it is the policy of the facility to provide a safe environment where residents are not subject to mental, physical, sexual, and verbal abuse or neglect by staff, residents, volunteers, consultants, contractors, and other caregivers, visitors or family members. The current policy titled Identifying Types of Abuse last reviewed by the facility on September 6, 2024, defined sexual abuse as non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to: a. Unwanted intimate touching 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.
- Potential for harm · D2025-01-24 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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
review, and staff interview it was revealed the facility failed to implement its abuse prohibition procedures to identify potential sexual abuse, timely notify administration and the State Survey Agency, report to the resident representatives and physician, and promptly investigate alleged sexual abuse of one resident out of 27 sampled (Resident 289). Findings include: Review of the facility policy titled Abuse Prohibition last reviewed September 6, 2024, revealed all allegations of abuse shall be reported immediately to the Charge Nurse, Director of Nursing, Administrator, and resident's physician for investigation into the circumstances of the incident. The staff member who discovers the incident, suspected abuse situation or has the initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The supervisor who becomes aware of such incidents must immediately report to the Administrator and Director of Nursing, in person or by telephone. The facility's abuse policy defines sexual abuse as non-consensual sexual contact of any type with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and staff interview it was determined the facility failed to provide documented evidence that interventions for significant weight loss were consistently implemented as planned to promote weight stabilization for one resident (Resident 67) out of seven sampled residents at nutritional risk. Findings include: A review of facility policy entitled Weighing of Residents, last reviewed by the facility on September 6, 2024, indicated that interventions for undesirable weight loss should focus first on food (e.g., extra food, snacks, calorie-dense food, etc.) based on the resident's current food preferences. Liquid nutritional supplements, per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase weight. Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician may order tests, appetite stimulants, or medications as appropriate. The suggested…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-24 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and resident and staff interview, it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for two residents out of three sampled receiving hemodialysis (Residents 121 and 187). Findings include: According to the National Kidney Foundation, patients receiving hemodialysis (a lifesaving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) should keep emergency care supplies on hand in case of complications related to their dialysis access site. A review of the facility policy titled Care of Dialysis Resident last reviewed by the facility on September 6, 2024, revealed that if a resident has a temporary catheter for dialysis, they are to always have an emergency protocol kit with them. Nurses are required to document in the electronic treatment administration record every four hours that the full kit is present with the resident. A review of Resident 121'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.
- Potential for harm · D2025-01-24 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of clinical records and staff interview, it was determined the facility failed to offer routine annual dental services for one Medicaid payor source (Resident 88) out of four residents sampled for dental services. Findings include: Review of Resident 88's clinical record revealed admission to the facility on March 24, 2021, and the resident's payor source was Medicaid. There was no documented evidence at the time of the survey ending January 24, 2025, the resident had been offered dental services in the past year. Interview with the Clinical Operations Executive on January 23, 2025, at 1:57 PM confirmed the facility had not offered Resident 88 routine dental services in the past year. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services
- Potential for harm · D2024-09-24 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined the facility failed to conduct meal service in a manner respectful of each resident's personal dignity for one of nine residents observed at the breakfast meal (Resident 43). Findings include: A clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 25, 2024, revealed that Resident 43 is severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-24 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined the facility failed to maintain accurate and complete clinical records for one of 10 sampled residents (Resident CR1). Findings include: A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood). A clinical record review revealed physician's orders for Resident CR1 to receive hospice services initiated on March 26, 2023, and for monthly weight monitoring to be discontinued on March 28, 2023. A review of a documentation survey report for August 2024 revealed 18 meals that had no documented information regarding Resident CR1 nutritional intake (percentage of meal eaten or amount of liquids consumed). A review of Resident CR1's progress notes from August 1, 2024, through August 29, 2024, revealed no documentation of the resident's nutritional intake. Further review of the clinical record revealed Resident CR1 and 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.
- Potential for harm · E2024-02-16 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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, a review of clinical records and activities programming and participation records, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests and functional abilities of residents including two of 25 sampled residents (Residents 83 and 117). Findings include: Review of Resident 117's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included major depressive disorder ([MDD] persistently low or depressed mood) and stage four sacral ulcer (a severe wound that extends past het skin and subcutaneous tissue, exposing muscle and bone). Review of an initial activities assessment dated [DATE], revealed that the resident enjoyed listening to oldies music and watching cooking shows on the television. Review of the resident's care plan dated November 21, 2023, revealed that the resident was dependent on staff for meeting emotional, intellectual,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-16 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 select facility policy and controlled drug shift count records, observation, and staff interviews, it was determined that the facility failed to implement procedures for reconciling and accounting for the use and administration of controlled drugs on three of five medication carts reviewed (3rd high, 3rd low, and 2nd). Finding include: A review of facility policy Controlled Medication last reviewed by the facility February 5, 2024, indicated that the policy is to ensure appropriate management and accounting of all controlled medications. All controlled medications will be counted by the on-coming and off-going licensed nurse at the change of each shift. After verification of the accuracy of the controlled substance count, both nurses will sign the Narcotic and Controlled Drug Record on the line corresponding with the appropriate date and shift. Observation of medication administration pass, on February 14, 2024, at approximately 8:25 AM, revealed Employee 5, Licensed Practical Nurse (LPN), was completing med pass on the 3rd floor high side medication cart. Upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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, a review of clinical records and interviews with staff it was determined that the facility failed to consistently provide a functional communication system to maintain the resident's ability to communicate for one of one residents sampled with communication needs/deficits (Resident 122). Findings include: A review of Resident 122's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including dementia. A review of Resident 122's nursing progress notes revealed a nursing note dated December 4, 2023, indicating that the resident's first language is Russian, further stating the resident's family helps her with translation. According to the resident's admission MDS assessment (Minimum Data Set assessment-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 4, 2023, the resident was sometime able to understand others and was sometimes understood. A review of resident's 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.
- Potential for harm · Dcited before2024-02-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, information submitted by the facility, and select facility reports and staff interviews, it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of one out of two sampled residents with wandering behavior (Resident 108) to maintain resident safety. Findings include: A review of the clinical record revealed that Resident 108 was admitted to the facility on [DATE], with diagnoses of Dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), macular degeneration, and osteoarthritis. A review of Resident 108's wander/elopement risk scale (a document used to rate an individual's risk of elopement) dated March 11, 2023, revealed that the resident scored a 10, indicating that the resident was at risk for elopement/wandering. A review of an Annual Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically 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.
- Potential for harm · Dcited before2024-02-16 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance and adequate hydration status for one resident receiving dialysis (Resident 54) out of 25 sampled. Findings include: A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease, diabetes, and end stage kidney disease with dependence on hemodialysis. A physician's order dated January 25, 2024, was noted for the resident to be maintained on a 1000 cc fluid restriction with the following breakdown of the fluid distribution: 7:00 AM - 3:00 PM shift nursing 240 ml. 3:00 PM - 11:00 PM shift nursing 120 ml. 11:00 PM - 7:00 AM. shift nursing 120 ml. A total of 520 ml of fluids provided by dietary each day. A review of the resident's January 2024 and February 2024 Documentation Survey Report failed to provide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 select facility policy, resident and staff interviews it was determined that the facility failed to ensure that resident's drug regimen was free of unnecessary antibiotic drugs for one out of five residents sampled prescribed antibiotic drugs (Resident 40). Findings included: A review of the facility's policy titled Antibiotic Stewardship Plan with a review date of August 23, 2023, states that antibiotic resistance is a major problem, it is imperative to protect agents available by judicious antimicrobial management, which improves resident outcomes and reduces the potential development of resistant infections. The guideline principles include timely and appropriate initiation of antibiotics, appropriate administration according to evidence-based practice, monitoring the effectiveness and promoting transparency and open communication. Review of Resident 40's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of cognitive…
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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$12,418 in federal fines across 1 penalty.
- $12,418 — penalty dated 2025-11-21
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| APPLEGATE, MARY ROSE | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2018 |
| AFFINITY HEALTH SERVICES | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2020 |
CMS files one row per role, so the 3 rows in the source record cover these 2 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.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395103. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, 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.