Clepper Manor
959 East State Street, Sharon, PA 16146 · For profit - Corporation · 54 certified beds · (724) 981-2750 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- the CMS record shows $169,599 in federal fines (most recent 2023-12-13)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 6.7% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.5% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.9% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.3% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.3% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.5% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 68.4% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 7.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.2% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.6% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 47.8% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 42.4% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 24.3% | 9.5% | 12.0% | worse |
§ 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.
56.4% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 56.4%CMS range 40.0–73.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.3–16.0 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 54 beds and averages 42.2 residents a day — about 78% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.58 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.17 hrs/resident/day on weekends vs 3.95 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.19 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
12 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · K2023-12-13 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to protect the residents' right to be free from neglect by not providing all necessary emergency services for one resident requiring cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). This failure placed 14 residents in an Immediate Jeopardy situation. (Closed Record Resident CR1 and Residents R2 through R14). Findings include: Review of the Abuse, Neglect and Exploitation policy, dated 5/19/23, stated Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy entitled Cardiopulmonary Resuscitation dated 5/19/23, revealed that if a resident experiences a cardiac arrest, facility staff will 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.
- Immediate jeopardy · K2023-12-13 · tag F0836 — patternEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to comply with professional standards of care in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required for one of one residents reviewed who had requested that cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) be administered in the event that they became unresponsive with no pulse and failed to provide all necessary emergency services for one resident requiring CPR. This failure placed 14 residents in an Immediate Jeopardy situation. (Closed Record Resident CR1 and Residents R2 through R14). Findings include: The Pennsylvania Code Title 49. Professional and Vocational Standards through the Department of State indicated under the Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human…
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 · D2025-04-04 · 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
Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to care and treatment of residents with urinary drainage catheters (a tube inserted into the bladder to facilitate urine drainage) for one of 12 residents observed with drainage catheters (Resident R2). Findings include: Review of Resident R2's clinical record revealed an admission date of 3/17/25, with diagnoses that included osteolysis (condition where bone tissue is broken down), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and urinary tract infection. Observation on 4/1/25, at 4:15 p.m. revealed Resident R2 lying in bed with his/her catheter drainage bag and tubing extended out and lying on the floor next to the bed. There was no cover over the drainage bag that was directly on the floor. During an interview at that time, Licensed Practical Nurse Employee E2 confirmed that the catheter drainage bag and tubing was laying on the floor…
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 · D2024-05-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) anti-anxiety psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had clinical rationale identified for the use beyond the limitation of 14 days for one of 11 residents (Resident R34). Findings include: A review of a facility policy entitled Use of Psychotropic Medication dated 2/21/24, stated PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for PRN order. Resident R34's clinical record revealed an admission date of 2/16/24, with diagnoses of encounter for palliative care (hospice…
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 · E2023-12-13 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to protect the residents' right to be free from neglect and to make certain that all emergency services were provided regarding residents requiring cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) as required by the facility. Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to direct the day to day functions of the facility in accordance with the current federal, state, and local standards, guidelines, and regulations that govern long term care facilities to assure that the highest degree of quality care can be provided to the residents at all times. Review of the job description for the DON revealed that the DON's purpose is to plan, organize, develop, control and direct the overall…
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 · E2023-06-02 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to ensure that the care plan review was completed and reviewed with the resident and/or resident representative for two of 12 residents reviewed (Residents R2 and R18) Findings include: Review of the Care-Planning Resident Participation policy, dated 5/24/23, revealed the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care conferences .the facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. Review of Resident R2's clinical record revealed an admission date of 11/27/20 with diagnoses that included heart failure, diabetes, difficulty swallowing, poor circulation, anxiety and hypertension. Review of the clinical record revealed that Resident R2 had a Quarterly Minimum Data Set (MDS-periodic review of resident care needs) on 8/17/22 and an Annual MDS review on 2/13/23. There was no evidence that a care plan meeting occurred, who attended or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-02 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of facility employee records and staff interview, it was determined that the facility failed to complete performance reviews of Nurse Aides (NA) at least once every 12 months for the past year from July 2022 through June 2023. Findings include: Upon request, no records or evidence of performance reviews for all NAs from July 2022, through June 2023, was provided for review. During an interview on 6/02/23, at 12:25 p.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding completed performance reviews for NAs as required every 12 months. 28 Pa. Code 201.20(a)(d) Staff development
- Potential for harm · E2023-06-02 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings for the past year from July 2022 through June 2023. Findings include: Upon request, no records or evidence of mandatory in-service training for all NA's from July 2022 through June 2023, was provided for review. During an interview on 6/02/23, at 11:40 a.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 201.20(a)(c)(d) Staff development
- Potential for harm · D2023-06-02 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of clinical records and facility documentation and staff and family interviews, it was determined that the facility failed to investigate a bruise of unknown origin for one of 12 residents (Resident R42). Findings include: Review of theInvestigation of Incidents and Accidents Education, sheet, dated 5/24/23, revealed when an unusual incident, injury/bruise (whether or not the origin is known) .the supervisor /charge nurse or appropriate department head will initiate and document an investigation of the accident or incident. 3. Notification of the physician, responsible party, Director of Nursing and Administration will be done promptly. 9. If a resident has an injury/bruise of unknown origin, witness statements will be obtained from the staff who cared for the resident and those who were on the unit or in contact with the resident for the 48-72 hour period prior to the discovery of the injury/bruise. Review of Resident R42's clinical record revealed an admission date of 10/12/21 with diagnoses that included lumbar disc degeneration, difficulty walking,…
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 · D2023-06-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of closed records, facility policy, and staff interview, it was determined that the facility failed to implement procedures to promote accurate and safe disposition of controlled medication records for one of two closed records reviewed (Resident R45). Findings include: Review of the facility policy, entitled Discarding and Destroying Medications, dated 5/24/23, indicated if a resident is transferred to another facility, or dies while he or she is in lawful possession of controlled substances, the facility may dispose of the controlled substance(s) by depositing in the authorized on-site receptacle. Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. Required documentation of the medication disposal on the medication disposition record included the signature(s) of at least two witnesses, the quantity disposed, and reason for disposition. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. Review of Resident R45'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.
- No harm found · B2025-04-04 · 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 review of clinical records and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) for four of four residents reviewed for bed holds (Residents R5, R8, R15, and R40). Findings include: Resident R5's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/12/25, and returned to the facility on 3/17/25, with a diagnosis of a urinary tract infection (infection in any part of your urinary system). Resident R8's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/25/25, and returned to the facility on 3/26/25, with a diagnosis of a cardiac event and orders to be place with a cardiac monitor. Resident R15's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/16/25, and returned to the facility on 3/21/25, with a diagnosis of acute respiratory failure (when 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.
- No harm found · C2023-06-02 · tag F0868 — widespreadHave 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 records and staff interview, it was determined that the facility failed to assure required attendance of the Medical Director and Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings quarterly for the meeting records reviewed from 7/27/2022 to 5/24/2023. Findings include: Review of the QAPI Committee Attendance Records revealed that the facility holds QAPI meetings monthly. Committee Members are required to attend and sign quarterly attendance sign-in sheets for the required quarterly meetings. Upon review of the QAPI Committee Attendance Records from 7/27/2022, to 5/24/2023, it was revealed that the Medical Director did not attend for five months from 9/21/2022, to 1/25/2023. The Infection Preventionist did not attend for six months between 12/28/2022, to 5/24/2023. During an interview on 6/2/2023, at 12:37 p.m. the Nursing Home Administrator confirmed that both the Medical Director and the Infection Preventionist did not attend the QAPI committee meetings as required. 28 Pa. Code 201.18(e)(1)(2)(3) Management
- 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
$169,599 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $169,599 — penalty dated 2023-12-13
- Medicare payment denial — starting 2024-08-01 for 13 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EMBASSY HEALTHCARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 3 of 5 | 1.8 | +1.2 vs chain |
| Quality measures | 3 of 5 | 4.4 | -1.4 vs chain |
The other 32 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EMBASSY PA TENTANT HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2020 |
| EMBASSY HEALTHCARE HOLDINGS INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 05/01/2020 |
| HANDLER, AARON | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2020 |
| REPCHICK, GEORGE | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2020 |
| EMBASSY HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/02/2025 |
| HERITAGE EMPLOYMENT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/02/2025 |
| SCARSELL, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/23/2023 |
CMS files one row per role, so the 13 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $205K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 396071. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-04, 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.