Shippenville Nursing And Rehab
21158 Paint Boulevard, Shippenville, PA 16254 · For profit - Limited Liability company · 120 certified beds · (814) 226-5660 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (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) | 2 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 | 2 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 4 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 | 19.4% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 11.0% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.6% | 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 | 6.8% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.0% | 17.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 27.6% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.5% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.1% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.9% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.4% | 17.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 83.1% | 68.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.8% | 22.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.9% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.32 | 1.62 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.61 | 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.
64.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 90 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.1% 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 44 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 64.9%CMS range 55.2–74.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 6.3–11.8 | 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 | 59.1% | 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 | 59.1% | 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 | 59.1% | 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 | 98.4% | 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 | 92.0% | 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 | 1.6% | 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 | 1.6% | 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 | 6.3%CMS range 3.5–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.62 | 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 120 beds and averages 96.3 residents a day — about 80% occupied, or roughly 24 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.546 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.63 on weekdays — 11% thinner on weekends. RN hours go from 0.62 to 0.36 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-06-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement an intervention in a comprehensive person-centered care plan for a resident requiring suctioning (a procedure to remove unwanted fluid from a person) for one of 19 residents reviewed. (Residents R12). Findings include: Review of facility policy entitled, Comprehensive Care Plan dated 1/22/26, indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. and Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Review of Resident R12's clinical record revealed an admission date of 1/8/18, with diagnoses that included multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), chronic obstructive pulmonary disease (when…
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 before2026-06-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of 19 residents reviewed (Resident R12).Findings include: Review of facility policy entitled Suctioning the Upper Airway dated 1/22/26, indicated Empty and rinse collection container if necessary or as indicated by facility protocol. Review of Resident R12's clinical record revealed an admission date of 1/8/18, with diagnoses that include multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and dysphagia (difficulty swallowing). Review of Resident R12's physician's orders revealed an order for suction every four hours if cannot clear secretions. Review of Resident R12's plan of care revealed a plan 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 · D2026-06-12 · 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
Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R27). Findings include: Review of the facility policy Hemodialysis, dated 1/22/26, indicated that the licensed nurse will communicate to the dialysis facility and attending physician medication administration or withholding of certain medications prior to the dialysis treatment and document such orders. Review of Resident R27's clinical record revealed an admission date of 4/09/26, with diagnoses that included heart disease, heart failure, acquired absence of right & left leg below the knee, type II diabetes ( the body does not make enough insulin to control blood sugar), and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, and Friday each week for dialysis treatments. Review of physician'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 · Dcited before2026-06-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed (B wing medication cart) and one of two medication rooms reviewed (200/300 medication room) and failed to prevent the opportunity for potential unauthorized access of medications on one of three medication carts observed (C wing medication cart). Findings include: Review of facility policy entitled Labeling of Medications and Biologicals dated 1/22/26, indicated Labels for multi-use vials must include: The date the vial was initially opened or accessed.All opened or accessed vials should be discarded within 28 days. Review of facility policy entitled Medication Storage date 1/22/26, indicated During a medication pass, medications must be under the direct observation of the person administering medications, or locked in the medication storage area/cart. Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin must be used within 28 days after opening or be…
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 before2026-06-12 · 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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross-contamination during completion of a wound dressing change for one of 19 residents reviewed (Resident R29).Findings include: Review of facility policy entitled Wound Care dated 1/22/26, indicated Steps in the procedure. Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves. Observations on 6/11/26, at 11:01 a.m. revealed Registered Nurse (RN) Employee E1 completing a wound dressing change in Resident R29's room. During the dressing change RN Employee E1 removed a soiled dressing from Resident R29's coccyx. He/she then proceeded to clean the wound without washing his/her hands and changing his/her gloves after removing the soiled dressing. During an interview on 6/11/26, at 11:15 RN Employee E1 confirmed that he/she did not wash their hands or change gloves after removing the soiled dressing. RN Employee E1 also confirmed…
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 before2026-04-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of three residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 12/17/25, with diagnoses that included weakness, uncontrolled seizures and an inability to eat food by mouth. Resident R1's clinical record revealed a physician's order dated 12/17/25, that directed the administration/infusion of liquid nutrition/food by a gastric tube (a tube inserted into the stomach through which medications and liquid food can be administered), to run continuously at 50 cc's per hour. Resident R1's clinical record revealed a nurse's note at 9:12 p.m. on 12/30/25, that documented an observation that Resident R1's continuous tube feed infusion was not infusing as physician ordered. During interview on 4/18/26, at approximately 10:05 a.m., the Director of Nursing confirmed that the above nurse's note was correct, Resident R1's tube feed solution had not been infusing for approximately four…
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 · E2025-06-13 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, facility documents, and resident and staff interviews, it was determined that the facility failed to correct Resident Council concerns for a period of six months (January 2025 through June 2025). Findings: Review of facility policy, Resident Council, dated 2/18/25, indicated A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from Resident Council as part of their quality review. Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.). Review of the Resident Council minutes and Grievances over the past six months, January 2025 through June 2025, revealed a pattern/trend with issues regarding residents not receiving ice water. During a Resident Council meeting on 6/11/25, at 10:30 a.m. interviews…
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 · E2025-06-13 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policies and facility documents, observations, resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for 10 of 26 residents interviewed (Residents R3, R7, R21, R27, R42, R60, R76, R77, R93, and R199). Findings include: Review of facility policy entitled, Answering the Call Light dated 2/18/25, revealed If the resident's request is something you can fulfill, complete the task within five minutes if possible. Review of facility policy entitled Resident Showers dated 2/18/25, revealed Residents will be provided showers as per request or as facility schedule protocols . Review of facility policy entitled Activities of Daily Living (ADLs), Supporting dated 2/18/25, revealed Appropriate care and services will be provided for residents who are unable to carry out ADLs . Hygiene (bathing .). Review of facility job descriptions for a Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 review of facility policies, observations, and staff interview, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line and ensure that food was stored in accordance with standards for food safety in the main kitchen, and resident pantries (D Wing, A Wing, Skilled Wing pantries and Kitchen). Findings include: Review of a facility policy entitled Floor stock and Supplement Distribution dated 2/18/25, revealed discarding expired and unlabeled products ., Supplements such as . Med Pass . will be dated upon opening and will have a three day use by date ., and Cleaning and sanitizing the unit pantry and refrigerator/freezers. Review of a facility policy entitled Food: Safe Handling for Food from Visitors dated 2/18/25, revealed Label food with the resident name and the current date and daily monitoring for refrigerator storage duration and discard of any food items that have been stored for seven or greater days. Review of a facility policy entitled Staff Attire dated 2/18/25, revealed The Dining Service Director ensures that all…
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 · D2025-06-13 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to assure physician orders and resident's Pennsylvania Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for two of 22 residents reviewed (Residents R46 and R60). Findings include: Review of facility policy entitled Advance Directives dated [DATE], revealed Upon admission, the resident will be provided with written information concerning the right to refuse or accept . and to formulate an advance directive ., Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. And The Director of Nursing Services . of advance directives so that appropriate orders can be documented in the resident's medical record . Review of Resident R46's clinical record revealed an admission date of [DATE], with diagnoses that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2025-06-13 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, clinical records and staff interview it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of four residents reviewed (Resident R46). Findings include: Review of facility policy entitled Transfer and Discharge (including AMA[against medical advice]) dated 2/18/25, revealed For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who is responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; . and Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative . Review of Resident R46's clinical…
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 · D2025-06-13 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 26 residents reviewed (Residents R15, R51 and R89). Findings include: A facility policy entitled Care Plans-Baseline dated 2/18/25, revealed The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident R15's clinical record revealed an admission date of 4/18/25, with diagnoses that included sacrococcygeal disorders (a range of conditions affecting the sacrum and coccyx [triangular bone and tailbone at the base of the spine], including pain, tumors, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to ensure that a resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of three residents reviewed (Resident R5). Findings include: Review of facility policy entitled Resident Mobility and Range of Motion dated 2/18/25, indicated Residents with limited range of motion (ROM) will receive treatment and services to increase and/or prevent a further decrease in ROM. And Residents with limited mobility will receive appropriate services, equipment . to maintain or improve mobility . Review of Resident R5's clinical record revealed an admission date of 2/4/25, with diagnoses that included hemiplegia and hemiparesis (a condition where a person is paralyzed and unable to move one side of their body and muscle weakness), hypertension (high blood pressure), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review 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 · Dcited before2025-06-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R18). Findings include: Review of facility policy entitled Oxygen Administration dated 2/18/25, revealed Verify that there is a physician's order for this procedure. Review the physician's orders . Turn on oxygen. Unless otherwise ordered, start the flow of oxygen at . and adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of Resident R18's clinical record revealed an admission date of 11/7/20, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes (a health condition that caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R18's physician's orders revealed an order dated 6/18/22, for oxygen at 2 liters/minute…
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 before2025-06-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner for two of three medication carts reviewed (A Wing medication and Skilled Wing medication cart). Findings include: Review of a facility policy entitled Medication Storage dated 2/18/25, revealed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Manufacturer's recommendations for Latanoprost (a type of eye drop), indicated that once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for six weeks. Manufacturer's recommendations for Lantus (a long-acting insulin), indicated that an opened multiple-dose vial stored at room temperature…
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 before2025-06-13 · 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 review of facility policies, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross-contamination during completion of a wound dressing change for one of one residents reviewed (Resident R75). Findings include: Review of facility policy entitled Wound Care dated 2/18/25, indicated Wipe reuseable supplies with alcohol as indicated (i.e., scissor blades .) Review of facility policy entitled Cleaning and Disinfection of Resident Care-Items and Equipment dated 2/18/25, indicated Reusable items are cleaned and disinfected or sterilized between residents . Observations on 6/12/25, at 1:50 p.m. revealed Licensed Practical Nurse (LPN) Employee E7 completing a wound dressing change in Resident R75's room. During the dressing change LPN Employee E7 used scissors to cut the soiled dressing from Resident R75's right foot. LPN Employee E7 then placed the scissors on a towel covering Resident R75's bedside table. After completing the dressing change LPN Employee E7 picked up the scissors and placed them in their pocket without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-01 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure the physician was contacted regarding an incomplete order prior to medication administration for one of eight residents reviewed (Resident R1). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of the facility's job description for RNs revealed The purpose of the RN is 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 before2025-05-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records and staff interview, it was determined that the facility failed to enter physician's orders timely resulting in a delay in treatment for one of eight residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admission date of 4/8/25, with diagnoses that included osteomyelitis (an infection in the bone), weakness, and type II diabetes (the body does not use insulin properly). Resident R1's clinical record revealed he/she arrived at the facility on 4/8/25, at approximately 10:00 a.m. His/her medication orders which included Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams (an antibiotic used to treat many different infections caused by bacteria) were not entered into the facility electronic health record system for the nurses to be alerted when the medication was due to be administered. This resulted in Resident R1 missing his/her noon dose of Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams and his/her 6:00 p.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · 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
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean and sanitary resident common area for one of four resident units (Alzheimer's Care Unit). Findings include: Review of facility policy entitled Quality of Life - Homelike Environment dated 2/18/25, indicated The facility staff and management shall maximize .the characteristics of the facility that reflect . homelike setting. Clean, sanitary and orderly environment. Observations on 2/29/25, at 10:00 a.m. of the Alzheimer's Care Unit (ACU) revealed three sitting chairs and a couch in the common area. The chairs and couch cushions had several areas of a brown substance which appeared to be stains caused from moisture. The arms of the furniture had rips in the fabric and the stuffing was coming out. On the wall in the common area was a box with television cable attached to it, the box was pulling off of the wall. Observations of a resident room revealed a curtain covering a window with the fabric on the back of the curtain ripped and hanging down.…
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 before2025-02-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure medications are obtained from pharmacy in a timely manner for one of 12 residents reviewed (Resident R1). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 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 nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place and 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse…
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 before2025-02-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, facility documents, and staff interview, it was determined that the facility failed to follow physician's orders related to a medication order resulting in a delay in treatment for one of 12 residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admission date of 10/30/2024, with diagnoses that included dementia (a group of thinking and social issues that interfere with daily living), parkinsonism (a central nervous system disorder that affects movements), and anxiety. Resident R1's clinical record progress notes documented that on 11/04/2024, Resident R1 was tired and had a fever. He/she was tested for COVID, with positive results. At that time, the physician was contacted, and an order was received to give Paxlovid (300/100) (an antiviral medication used to treat mild to moderate COVID) oral tablet therapy give two tablets by mouth two times a day for COVID starting on 11/05/2024, for five days. Review of facility documents from pharmacy dated 11/1/2024, through 11/7/2024, revealed that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · 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
Based on review of facility policies, clinical records, facility documents, and staff interviews, it was determined that the facility failed to maintain complete and accurate clinical records for one of 12 residents reviewed (Resident R1). Findings include: Review of facility policy entitled, Administering Medications dated 2/18/2025, revealed The individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. Review of the facility policy entitled, Change in a Resident's Condition or Status dated 2/18/2025, revealed The nurse will notify the resident's attending physician on call when there has been a need to transfer the resident to a hospital/treatment center . Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: it is necessary to transfer the resident to a hospital/treatment center .The nurse will record in the resident's medical record information relative to the changes in the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0641 — isolatedEnsure 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 clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 19 residents reviewed (Resident R50). Findings include: Review of Resident R50's clinical record revealed an admission date of 8/02/22, with diagnoses that included Alzheimer's disease (a disease that affects short term memory and the ability to think logically), anxiety, depression, diabetes and high blood pressure. Review of Resident R50's clinical record revealed that the resident sustained a fall on 4/16/24, without injury. Nurses notes dated 4/20/24, revealed that a large bruise was noted to Resident R50's right ribs and that resident had a recent fall on 4/16/24. Nurses note dated 4/21/24, revealed x-ray results of the right rib received showing a right 8th anterior rib fracture and possibly the 7th rib also. Review…
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 · D2024-07-11 · 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 provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of 19 residents reviewed (Resident R57). Findings include: A facility policy entitled Antipsychotic Medication Use dated 1/19/2024, indicated that PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rational for continued use. The duration of the PRN order will be indicated in the order. Resident R57's clinical record revealed an admission date of 11/11/20, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), arthritis (a condition when there is swelling and tenderness of one or more joints in the body), and cerebral atherosclerosis (a disease where blood vessels become blocked and decrease blood flow…
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 before2024-07-11 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of three medication carts reviewed (B wing skilled and A wing medication carts). Findings include: Review of facility policy entitled Medication Storage in the Facility dated 1/19/24, indicated Outdated, contaminated or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal . Review of manufacturer's guidelines revealed that an open vial of Humalog Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of manufacturer's guidelines revealed that an open vial of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on 7/8/24, at 3:55 p.m. of A wing medication cart revealed an open vial of Lantus with an open date of 6/9/24, which was beyond the 28 days after opening. Observation of drug storage on 7/8/24,…
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.
- 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
No federal fines in the current CMS record.
Part of a chain
This home belongs to VALLEY WEST HEALTH — 12 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 | 3.3 | -0.3 vs chain |
| Health inspection | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 3 of 5 | 3.1 | -0.1 vs chain |
The other 11 homes this chain runs (chain average 3.3★, 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 |
|---|---|---|---|---|
| WESTERN PA OPCO HOLDINGS I LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 10/29/2024 |
| VALLEY WEST HEALTH LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/24/2025 |
| FRANCO, AHARON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/24/2025 |
| RAMI, ISAAC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/24/2025 |
| BEVERLY ENTERPRISES - PENNSYLVANIA, INC. | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| BEVERLY ENTERPRISES LLC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| BEVERLY HEALTH AND REHABILITIATION SERVICES, INC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| DRUMM INTERMEDIARY SUB CO LLC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| DRUMM MERGER CO | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| DRUMM MERGER CO SUB LLC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| FILLMORE STRATEGIC INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| GEARY PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| GPH SHIPPENVILLE LP | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| ISKEB 2024 TRUST | Organization | ADP OF THE SNF | — | since 01/24/2025 |
| ISKEB WESTERN PA LLC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| KEYSTONE VENTURES LLC | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| PEARL SENIOR CARE, LLC. | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| SURETY COMPLIANCE | Organization | ADP OF THE SNF | — | since 01/24/2025 |
| WASHINGTON STATE INVESTMENT BOARD | Organization | ADP OF THE SNF | — | since 12/17/2024 |
| ANDREWS, HEATHER | Individual | ADP OF THE SNF | — | since 01/24/2025 |
| FINN, NICHOLAS | Individual | ADP OF THE SNF | — | since 01/24/2025 |
| HICKS, BARBARA | Individual | ADP OF THE SNF | — | since 12/17/2024 |
| KARITY, SARAH | Individual | ADP OF THE SNF | — | since 01/24/2025 |
| LINAM, KIM | Individual | ADP OF THE SNF | — | since 01/24/2025 |
| MILLER, JEAN | Individual | ADP OF THE SNF | — | since 01/24/2025 |
| POLITO, MELISSA | Individual | ADP OF THE SNF | — | since 12/17/2024 |
| RASMUSSEN-JONES, HOLLY | Individual | ADP OF THE SNF | — | since 01/24/2025 |
| ROSSINO, SUSEN | Individual | ADP OF THE SNF | — | since 12/17/2024 |
CMS files one row per role, so the 32 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted.
17 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.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 395607. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-12, 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 →
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