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Sinking Spring Skilled Nursing And Rehabilitation

3000 Windmill Road, Sinking Spring, PA 19608 · For profit - Corporation · 214 certified beds · (610) 670-2100 Medicare & Medicaid certified

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Flagged for abuseResident-funds citation (F0569)Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$17,342 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0569)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,342 in federal fines (most recent 2025-03-27)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Urgent care / clinic
310 W Wyomissing Blvd · (610) 743-4788 · Call to confirm hours
Pharmacy
3100 Shillington Rd · (610) 678-9054 · Call to confirm hours
Grocery
Lidl0.4 mi
3564 Penn Ave · (888) 654-3515 · Call to confirm hours
Park
2715 Hillvale Ave · Typically dawn to dusk
Place of worship
168 Shillington Rd · (484) 878-5860

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.5%16.8%15.4%typical
Long-stay residents who lose too much weight8.1%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.1%0.7%0.9%better
Long-stay residents with a urinary tract infection1.8%1.5%2.0%typical
Long-stay residents with depressive symptoms10.2%10.8%6.5%worse
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened13.1%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.3%20.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers4.2%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control25.2%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table28.7%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine87.5%68.7%79.4%better
Short-stay residents rehospitalized after admission25.1%22.5%22.6%worse
Short-stay residents with an outpatient ER visit6.5%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.611.621.67typical
Long-stay outpatient ER visits per 1,000 resident days0.651.181.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

42.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 158 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.5%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
34.6%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 34.6% 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 78 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.5%CMS range 34.6–50.451.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.2–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge34.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge35.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge29.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.6–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.781.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.35
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.20
Total nurse hours/ resident / day
0.22
RN hoursweekends
46.1%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 214 beds and averages 192.1 residents a day — about 90% occupied, or roughly 22 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.02 hrs/resident/day on weekends vs 3.28 on weekdays — 8% thinner on weekends. RN hours go from 0.41 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

3
deficiencies at the latest standard inspection (2025-09-26)
9
at the previous standard inspection (2024-08-27)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-01-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 facility policy review, clinical record review, observation, and resident and staff interviews, it was determined the facility failed to ensure that residents were free from physical and mental abuse for one of seven sampled residents. (Resident 1) This failure resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed April 17, 2025, revealed that the facility prohibited abuse, mistreatment, and neglect for all residents. The policy further defined abuse as willful infliction, meaning the individual acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the facility policy entitled, Treatment: Considerate and Respectful, reviewed, February 21, 2025, revealed that residents were to be groomed as they wished to be groomed, which included maintaining the resident's personal preference regarding hair style and length. Clinical record review revealed that Resident 1 had diagnoses that included chronic pain syndrome, major depressive disorder, and anxiety. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2026-01-08 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to provide care and services in a manner that respected each resident's dignity and preferences to promote quality of life, resulting in psychosocial harm for one of seven sampled residents. (Resident 1)Findings include: Review of the facility policy entitled, Treatment: Considerate and Respectful, reviewed February 21, 2025, revealed that residents were to be groomed as they wished to be groomed, which included maintaining the resident's personal preference regarding hair style and length. Clinical record review revealed that Resident 1 had diagnoses that included chronic pain syndrome, major depressive disorder, and anxiety. The Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs) dated November 6, 2025, revealed the resident was alert and oriented, reported feeling down, depressed or hopeless several days per week, and was dependent on staff for assistance with personal hygiene. Review of Resident 1's care plan revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-03-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, review of facility documentation, and resident interview, it was determined that the facility failed to ensure that residents were free from mental and/or physical abuse for two residents (Residents 1 and 2), which resulted in psychosocial harm for one of seven residents reviewed. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed February 21, 2025, revealed that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It included a resident's right to be free from verbal abuse, sexual abuse, physical abuse, and mental abuse. Clinical record review revealed that Resident 1 (R1) was admitted to the facility on [DATE], and had diagnoses that included hemiplegia and hemiparesis (paralysis on one side), anxiety, depression, and heart disease. Review of the Minimum Data Set (MDS) assessment (a periodic assessment of resident care…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of seven sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Medication Administration General Guidelines, dated February 12, 2026, revealed that medications were to be administered in accordance with written orders of the prescriber and that medications to be given at bedtime were to be scheduled for administration up to one hour prior to the resident's scheduled bedtime. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included Hodgkin's lymphoma (cancer of the lymph nodes) and anxiety. A physician's order, dated October 27, 2025, directed staff to administer lorazepam tablet 0.5 milligrams (mg), three tablets at bedtime. Review of nursing progress notes and the Individual Patient Narcotic Dispensing Record (a record kept to keep count of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of seven sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included chronic pain syndrome, major depressive disorder, and anxiety. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated November 6, 2025, the resident was alert and oriented, reported feeling down, depressed or hopeless several days per week, and was dependent on staff for assistance with personal hygiene. Review of Resident 1's care plan revealed that she often refused care due to her personal preference and staff was to postpone the activity if refused. In an interview on January 8, 2026, at 10:20 a.m., Resident 1 stated that staff cut her hair and took her for a shower, even though she refused. In an interview on January 8, 2026, at 12:14 p.m., the Director of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-09-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, it was determined that the facility failed to maintain sanitary conditions in the kitchen.Findings include:Observation during the environmental tour on September 23, 2025, at 10:10 a.m. revealed a black substance on ceiling tiles in the kitchen around the exhaust vents. Several ceiling tiles were missing, and a central air vent was dripping water onto the floor.CFR 483.60(i) Food Safety RequirementPreviously cited 8/27/2428 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(2.1) Management.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for three of 37 sampled residents. (Residents 9, 10, 11)Findings include: Clinical record review revealed that Resident 9 had diagnoses that included cerebral palsy and a seizure disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 9 required maximum assistance with hygiene and self care and had no cognitive impairment. Review of the care plan dated July 22, 2025, revealed that staff were to assist the resident with hygiene and self care, including nail care on bath day and as necessary. On September 23, 2025, at 2:58 p.m., the resident was observed in his room. His nails were long and dirty. He stated that he preferred short nails and that staff had not offered to provide nail care recently. On September 25, 2025, at 10:49 a.m., the resident was observed in bed. His nails remained long. He stated that staff had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-26 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff on one of four toured nursing units. (Station 2) Findings include:Observations on September 23, 2025, from 9:45 a.m. through 1:00 p.m. and on September 24, 2025, from 9:00 a.m. through 1:00 p.m. revealed the following:Peeling wallpaper was observed on all four walls in the Chapel.The wall to the left of the door was damaged in room [ROOM NUMBER].The wall behind the bathroom sink and toilet, and linoleum below the sink were damaged in room [ROOM NUMBER].In an interview on September 25, 2025, at 1:11 p.m., the Administrator confirmed that the environmental problems should have been addressed.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18 (b) (1) Management.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-09 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 resident fund accounts, clinical record, and staff interview, it was determined that the facility failed to convey resident funds and provide a final accounting of funds within 30 days of death to the individual/probate jurisdiction for the resident's estate for one of four residents (Resident 1). Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and expired on [DATE]. Review of Resident 1's account managed by the facility revealed that the account was closed on [DATE], with a balance of $2,961.70. There was no documented evidence that the facility provided a final accounting to the individual/probate jurisdiction for the resident's estate within 30 days of the resident's death. On [DATE], a check was made out to the Social Security Administration and not Resident 1's estate. In an interview on [DATE], at 1:30 p.m. the Administrator confirmed that there was no evidence that the facility provided a final accounting to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to report an allegation of abuse to the State Survey Agency for one of seven sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed February 21, 2025, revealed that the Administrator or designee would report allegations of abuse to the appropriate state and local authority within two hours. Clinical record review revealed that Resident 1 (R1) had diagnoses that included hemiplegia and hemiparesis (paralysis on one side), anxiety, depression, and heart disease. Review of a grievance form dated March 17, 2025, revealed that in the morning during the day shift (7:00 a.m. to 3:00 p.m.), R1 reported to staff that Resident 2 (R2) had been sexually harassing him by making threats if he didn't provide food and money and would hit his arm. Additional documentation indicated that on the same day and shift, R1 reported to the psychologist that R2 had been threatening and sexually harassing him with…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess wounds or implement interventions to prevent new or worsened pressure ulcers for two of five sampled residents with wounds. (Residents 1 and 3) Findings include: Review of the facility policy entitled, Skin Integrity and Wound Management, last reviewed October 15, 2024, revealed that staff was to assess and document wound status weekly. The nursing assistant would observe skin daily and report any changes or concerns to the nurse. The licensed nurse would perform daily monitoring of wounds or dressings for the presence of complications or decline. Documentation was to include daily monitoring of the ulcer/wound site with or without a dressing, status of the dressing, status of the tissue surrounding the dressing, adequate control of wound associated pain, and signs of decline in wound status. Pressure injury prevention was to be implemented for identified, modifiable risk factors. Clinical record review revealed that Resident 1 had diagnoses that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, policy review, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one resident on one of five nursing units. (Station 2, Resident 87) In addition, the facility failed to ensure that a call bell was answered in a timely manner for one of 35 sampled residents. (Resident 112) Findings include: Clinical record review revealed that Resident 87 had diagnoses that included Alzheimer's disease, dysphagia (difficulty in swallowing), and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated August 14, 2024, revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of Resident 87's care plan revealed that staff was to provide total assistance with feeding, feed the resident slowly, and provide verbal cueing with meals. On August 25, 2024, from 12:16 p.m. through 12:35 p.m., nurse aide (NA) 1 was observed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of five nursing units. (Medbridge, Station 2, and Arcadia) Findings include: Observations during the environmental tour on the Medbridge unit on August 25, 2024, at 12:30 p.m., revealed that in room [ROOM NUMBER], there was a large brown stain in the bathoom sink. There was also a black substance around and inside of the drain plug in the bathroom sink. Observation on August 25 and 26, 2024, in the morning and in the early afternoon at various times, revealed that there was a box outside of room [ROOM NUMBER] that contained a new toilet. In addition, observation on August 26, 2024, at 10:00 a.m, revealed there were two large garbage cans outside of room [ROOM NUMBER] that were uncovered. The one can was overflowing with trash. The box with the new toilet in it, and the two large garbage cans were cluttering this area near the nursing station and room [ROOM NUMBER]. Observations during…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited before2024-08-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 35 sampled residents. (Resident 189) Findings include: Clinical record review revealed that Resident 189 was admitted to the facility on [DATE], and had diagnoses that included anxiety and psychotic disorder with delusions. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 9, 2024, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration records revealed the resident was receiving both an antipsychotic and antidepressant at the time of the MDS CAA summary. There was no documented evidence that interventions to address Resident 189's psychotropic drug use were included in the current care plan. In an interview on August 27, 2024, at 10:25 a.m., the Administrator confirmed there was no documented evidence that…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-27 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and resident and staff interview, it was determined that the facility failed to provide services to improve activities of daily living (walking) for two of five sampled residents who required assistance with walking. (Residents 128, 157) Findings include: Clinical record review revealed that Resident 128 had a diagnosis of disorder of the muscle. Review of nursing documentation revealed that she also had difficulty walking and had a history of repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that she was alert and oriented and utilized a walker. A review of the care plan revealed that she had a self care deficit with activities of daily living (ADL)'s due to physical limitations. There was an intervention for her to ambulate with a wheeled walker 20 feet with stand by assistance. Review of a physical Discharge summary dated [DATE], revealed that the therapist recommended a restorative ambulation program. The resident was to safely ambulate up…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-27 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of five nursing units. (Medbridge) Findings include: Review of Dining Council Minutes from August 14, 2024, revealed that residents had stated that their food gets served cold. In a group interview on August 26, 2024, at 10:30 a.m., Residents 59, 149, and 168 revealed that it is an ongoing problem that hot food is frequently served cold. Review of facility documentation entitled, Food and Nutrition Services Test Tray Evaluation, the hot main entree, starch and vegetable should be greater than 140 degrees Fahrenheit (F) at point of service to the resident. Results of a test tray audit conducted on August 26, 2024, at 12:15 p.m., after the last resident meal tray was served from the dining cart, revealed a smothered pork chop was served at a temperature of 112.6 degrees F and the roast potatoes at a temperature of 108 degrees F. Both food items were cool to taste.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-27 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that residents were served preferred and selected food items on their meal trays for two of 35 sampled residents. (Resident 199, 202) Findings include: Clinical record review revealed that Resident 199 had a diagnosis of an adjustment disorder with mixed anxiety and depressed mood. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. A review of the care plan revealed that the resident was at nutritional risk due to a history of weight loss. There was an intervention for staff to honor food preferences within the meal plan. In an interview on August 25, 2024, at 10:30 a.m., the resident stated that frequently, he did not receive food and drink items that he had selected for his meals. Review of the current menu revealed that the lunch meal for August 26, 2024, was cheese lasagna and garlic bread. On August 26, 2024, at 12:15 p.m., the resident…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-27 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review and observation, it was determined that the facility failed to properly store food and maintain sanitary conditions on two of four unit pantries. (Station 2 and Arcadia) Findings include: Review of the facility policy entitled, Food Brought in for Residents, last reviewed April 3, 2024, revealed that staff were to label food items requiring refrigeration with the resident's name and date the food was brought in and the food would be discarded after three days by staff upon notification to the resident. Observation of the Arcadia unit pantry on August 25, 2024, at 10:32 a.m., revealed a sign on the refrigerator door that it was for resident food only and that foods must be discarded after three days. In the freezer, there was a layer of sticky, dried liquid with two strands of hair. There were three containers of raspberry orange sherbet and frozen grape concentrate that were not labeled with a resident's name or date. In the refrigerator, there was a container of dished applesauce dated August 21, 2024, a bottle of milk with an opening date of August…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on four of five nursing units. (Medbridge, Arcadia, Stations 2 and 3) Findings include: Observation of the Medbridge unit, on July 24, 2024, at 10:02 a.m., revealed a broken and rusted toilet seat in room [ROOM NUMBER]. There was also an accumulation of dirt and debris under the air conditioning unit in room [ROOM NUMBER]. In room [ROOM NUMBER], the bathroom light did not illuminate. Observations on the Arcadia unit, on July 24, 2024, at 10:10 a.m., revealed an accumulation of dirt and debris under the air conditioning unit in room [ROOM NUMBER]. Observations on Station 2, on July 24, 2024, at 10:15 a.m., revealed Resident 3's wheelchair to have an accumulation of dirt and debris on the bars. Observations on Station 3, on July 24, 2024, at 10:25 a.m., revealed the bathroom floor linoleum lifting from the floor in room [ROOM NUMBER]. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of ten sampled residents. (Residents 1, 10) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included hemiplegia and diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and required staff assistance for bathing. The resident was to receive a shower twice per week. During an interview on June 6, 2024, at 11:45 a.m., the resident reported that he preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 1 stated that he would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower four of nine scheduled times in the past 30 days. Clinical record review revealed that Resident 10 had diagnoses that included…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's responsible party of a significant change in condition and the resident's treatment for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, pneumonia, diabetes, and chronic kidney disease. On October 12, 2023, an open area was found on the resident's left buttock. A physician's order dated October 13, 2023, directed staff to cleanse the area and apply a dressing on Monday's, Wednesday's and Friday's for wound care. There was a lack of documentation to support that the resident's responsible party was notified of the open area and change in treatment. In an interview on October 28, 2023, at 2:04 p.m., the Unit Manager confirmed there was no documentation to support the resident's responsible party had been notified of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during the environmental tour on September 26, 2023, at 9:45 a.m. revealed flying insects in various areas of the kitchen. The areas included the dry storage area, cook's area, preparation area, and dish washing area. Pa Code 201.18 Management (e)(2.1).

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of five nursing units. (Heritage, Station 2, Station 3) Findings include: Observations during the environmental tour of the Heritage nursing unit on September 26, 2023, at 10:58 a.m. through September 28, 2023, at 11:30 a.m., revealed that in room [ROOM NUMBER], the walls were marred, there was exposed drywall on the bottom corner outside the bathroom wall, the rubber baseboard molding was seperated from the wall along the bottom corner outside the bathroom, and the raised toilet seat was loose. In room [ROOM NUMBER], bed B, the walls were marred and scratched behind the bed, the rubber baseboard molding was seperated at the corner of the wall. Observation during the environmental tour of Station 2 on September 26, 2023, at 11:45 a.m. through September 28, 2023, at 12:10 p.m., revealed marred walls and chipped paint in rooms [ROOM NUMBER]. There were numerous tiny black flies observed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for residents unable to carry out activities of daily living for one of 36 sampled residents. (Resident 66) Findings include: Clinical record review revealed that Resident 66 had diagnoses that included stroke with left-sided hemiplegia (severe or complete loss of strength on one side of the body). The Minimum Data Set assessment dated [DATE], indicated that the resident was oriented and required extensive staff assistance for personal hygiene. The care plan identified that Resident 66 had difficulty caring for himself due to his physical limitations and interventions included that staff assist with daily hygiene and grooming. Observations on September 26, 2023, at 12:51 p.m., and September 27, 2023, at 10:00 a.m., revealed that Resident 66's fingernails on both hands were long and jagged with dirt underneath. In an interview on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for two of 36 sampled residents. (Residents 22, 58) Findings include: Clinical record review revealed that Resident 22 had diagnoses that included contracture, rheumatoid arthritis, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment and required extensive assistance from staff with personal hygiene and dressing. Review of the care plan revealed that the resident was to wear bilateral palm guards at all times except when care was being provided. Observations on September 26, 2023, from 10:56 a.m. through 1:15 p.m., September 27, 2023, from 11:15 a.m. through 1:20 p.m., and September 28, 2023, at 12:13 p.m., revealed that the resident was in bed while no care was being provided with no bilateral palm guards. Clinical record 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess nutritional status in a timely manner for two of 36 sampled residents. (Residents 88, 158) Findings include: Review of the facility policy entitled, Weights and Heights,, last reviewed August 11, 2023, revealed that the licensed nurse would notify the dietitian of significant weight changes and document the notification in the electronic record. Clinical record review revealed that Resident 88 had diagnoses that included gastro-esophageal reflux disease and atherosclerotic heart disease. Review of the care plan revealed Resident 88 was at nutritional risk with an intervention for her weights to be reviewed. On April 2, 2023, the resident weighed 222 pounds (lbs), and on May 3, 2023, the resident weighed 209.6 lbs, a loss of 5.59 percent. There was no documentation to support that the dietitian had been notified or addressed Resident 88's weight loss. Clinical record review revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD) for one of 36 sampled residents. (Resident 132) Findings include: Clinical record review revealed that Resident 132 had diagnoses that included PTSD, insomnia, and nightmare disorder. Review of a psychology consultation dated September 8, 2023, revealed that the resident had a diagnosis of PTSD and reported childhood abuse. In an interview on September 27, 2023, at 11:46 a.m., the resident stated he still thinks about his traumatic childhood and it continues to affect him. There was no assessment or care plan in Resident 132's clinical record that identified symptoms or triggers related to this PTSD diagnosis and there were no resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on September 29, 2023 at 10:18 a.m., the Director of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychoactive medication was limited to 14 days unless the physician documented in the clinical record the rationale for the PRN to be extended beyond 14 days for one of 36 sampled residents. (Resident 43) Findings include: Clinical record review revealed that Resident 43 had diagnoses that included anxiety and dementia. On August 3, 2023, a physician ordered that staff administer a psychoactive medication (clonazepam) every 12 hours as needed. The order for the clonazepam failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on September 29, 2023, at 11:00 a.m. the Director of Nursing confirmed that there was no evidence the physician documented a rationale for continuing the medication beyond 14 days. 28 Pa. code 211.12(d)(1)(5) Nursing services.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-08-27 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, it was determined that the facility failed to post accurate and current nurse staffing information. Findings include: Observations during tours of the facility conducted on August 25, 2024, at 9:05 a.m., and August 26, 2024, at 9:13 a.m., revealed that staffing information posted in the lobby was dated for August 23, 2024. In an interview on August 27, 2024, at 11:24 a.m., the Nursing Home Administrator confirmed that incorrect staffing information was posted. 28 Pa. Code 201.18(b)(3) Management.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-08-27 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the trash compactor on August 25, 2024, at 10:30 a.m., revealed there was garbage and debris, including used gloves, plastic food bags, plastic straws, and a gauze roll on the ground around the compactor. There was a full garbage bag stuck between the compactor and the ground. The top lid was wide open on the garbage dumpster that was full of trash bags. There was a walker next to the dumpster. 28 Pa. Code 201.18(b)(3)Management.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-09-29 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative(s) of transfer and the reasons for the move in writing for four of nine sampled residents who were transferred to the hospital. (Residents 66, 152, 173, 346 ) Findings include: Clinical record review revealed that Resident 66 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 152 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 173 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-09-29 · tag F0625 — pattern
    Notify 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident, family member, or legal representative at the time of transfer for four of nine sampled residents who were transferred to the hospital. (Residents 66, 152, 173, 346) Findings include: Clinical record review revealed that Resident 66 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident's responsible party or legal representatives were provided written information about the facility's bed-hold policy at the time of transfer. Clinical record review revealed that Resident 152 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident, resident's responsible party, or legal representatives were provided written information about the facility's bed-hold policy at the time of transfer.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$17,342 in federal fines across 1 penalty.

  • $17,342 — penalty dated 2025-03-27

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 GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 3 of 53.5-0.5 vs chain
The other 183 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Alexandria Care CenterLos Angeles, CA 1 of 5Bay Crest Care CenterTorrance, CA 1 of 5Bethlehem North Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bethlehem South Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bridgeville Rehabilitation & Care CenterBridgeville, PA 1 of 5Brightwood CenterFollansbee, WV 1 of 5Carlisle Skilled Nursing And Rehabilitation CenterCarlisle, PA 1 of 5Casa De Oro CenterLas Cruces, NM 1 of 5Devonshire Care CenterHemet, CA 1 of 5Gettysburg CenterGettysburg, PA 1 of 5Glenwood CenterFlorence, AL 1 of 5Heritage CenterHuntington, WV 1 of 5Hidden Valley CenterOak Hill, WV 1 of 5Inners Creek Skilled Nursing And Rehabilitation CeDallastown, PA 1 of 5Jersey Shore Skilled Nursing And Rehabilitation CeJersey Shore, PA 1 of 5Kingston Court Skilled Nursing And RehabilitationYork, PA 1 of 5Las Palomas CenterAlbuquerque, NM 1 of 5Lebanon Center, Genesis HealthCareLebanon, NH 1 of 5Lebanon Skilled Nursing And Rehabilitation CenterLebanon, PA 1 of 5Linden Grove Health Care CenterPuyallup, WA 1 of 5Magnolia RidgeGardendale, AL 1 of 5Marmet CenterMarmet, WV 1 of 5Meridian CenterHigh Point, NC 1 of 5Merry Wood LodgeElmore, AL 1 of 5Mount Olive CenterMount Olive, NC 1 of 5Mountain Ridge Center, Genesis HealthCareFranklin, NH 1 of 5Oak Grove CenterWaterville, ME 1 of 5Oceanside Skilled Nursing And RehabilitationHampton, NH 1 of 5Orchard Park Health Care & Rehab CenterTacoma, WA 1 of 5Parkersburg CenterParkersburg, WV 1 of 5Pembroke CenterPembroke, NC 1 of 5Pine LodgeBeckley, WV 1 of 5Playa Del Rey CenterPlaya del Rey, CA 1 of 5Pocahontas CenterMarlinton, WV 1 of 5Pottstown Skilled Nursing and Rehabilitation CentePottstown, PA 1 of 5Putnam CenterHurricane, WV 1 of 5Ridgewood CenterRidgewood, NJ 1 of 5Rio Rancho CenterRio Rancho, NM 1 of 5River City CenterDecatur, AL 1 of 5River Ridge CenterKennebunk, ME

Showing 40 of 183; lowest-rated first.

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 / managerTypeRoleShareSince
GENESIS PM PA OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/15/2022
FC-GEN OPERATIONS INVESTMENT LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
GEN OPERATIONS I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
GEN OPERATIONS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
GENESIS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
GENESIS HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
GENESIS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
GHC HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
SUN HEALTHCARE GROUP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/15/2022
BERG, MICHAELIndividualCORPORATE OFFICERsince 11/15/2022
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 04/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 04/01/2024
MARINITA, DOMNIQUEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/2025

CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$17.1M
Net patient revenuemost recent cost report
-5.2%
Operating marginrevenue minus expenses
$2.4M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 88%Medicare 3%Other / private 9%

About 88% 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 $2.4M 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

$290per resident / day
operating cost
$8,811per month
≈ monthly operating cost
$276per day
avg. revenue, all payers

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

What families pay in PA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.

Typical monthly cost in Pennsylvania
$11,954/mo
Nursing home (semi-private)
$13,688/mo
Nursing home (private)
$6,480/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395541. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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