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Nursing And Rehabilitation At The Mansion

1040-52 Market Street, Sunbury, PA 17801 · For profit - Limited Liability company · 70 certified beds · (570) 286-6922 Medicare & Medicaid certified

Call the home — (570) 286-6922 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Jan 2024Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$10,033 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,033 in federal fines (most recent 2024-01-19)
  • about 17% of its spending goes to commonly-owned related companies

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1072 Market St · (570) 286-8521 · Call to confirm hours
Pharmacy
Market St. · (570) 286-6711 · Call to confirm hours
Grocery
456 Market St · (570) 415-5480 · Call to confirm hours
Park
222 N 6th St · (570) 286-7820 · Typically dawn to dusk
Place of worship
800 Market St · (570) 742-8987

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 3 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 held steady at 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.

Overall rating3★
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 increased26.2%16.8%15.4%worse
Long-stay residents who lose too much weight10.3%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms6.8%10.8%6.5%typical
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury6.0%3.1%3.3%worse
Long-stay residents whose ability to walk worsened22.2%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.6%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.4%93.5%95.3%typical
Long-stay residents with pressure ulcers10.1%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control24.2%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.5%17.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.1%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine87.9%68.7%79.4%better
Short-stay residents rehospitalized after admission26.1%22.5%22.6%worse
Short-stay residents with an outpatient ER visit5.8%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.861.621.67worse
Long-stay outpatient ER visits per 1,000 resident days0.501.181.80better

§ 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.

53.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.7%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
52.4%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 52.4% 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 42 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF53.7%CMS range 42.4–67.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.2–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge52.4%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 discharge30.9%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 discharge45.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened0.0%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 hospitalization6.5%CMS range 3.7–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.70
RN hours/ resident / day
0.81
LPN hours/ resident / day
1.75
Aide hours/ resident / day
3.27
Total nurse hours/ resident / day
0.47
RN hoursweekends
20.8%
Total nursing turnover
11.1%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 65.8 residents a day — about 94% occupied, or roughly 4 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.39 on weekdays — 13% thinner on weekends. RN hours go from 0.79 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% is below 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

9
deficiencies at the latest standard inspection (2025-12-19)
10
at the previous standard inspection (2024-11-15)

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 11 most serious are shown; the remaining 21 are one tap away and print in full.

  • Actual harm · G2024-01-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to implement interventions and provide adequate supervision to prevent a fall for one of three residents reviewed for falls that resulted in harm (Resident 5). This deficiency is cited as past non-compliance. Findings include: Clinical record review revealed the facility admitted Resident 5 on March 26, 2015. Review of Resident 5's plan of care initiated on March 26, 2015, indicated that Resident 5 is at risk for falls related to her diagnosis of Alzheimer's dementia, history of falls, syncope, and noncompliance with assistance with transfers. Nursing documentation dated October 5, 2023, at 2:45 PM revealed the Director of Nursing was called to the front porch by staff asking for nursing assistance. Documentation revealed that upon reaching the porch the Director of Nursing was notified that Resident 5 had wheeled herself off the porch and down the steps. Resident 5 was noted to be lying…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2025-12-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined that the facility failed to prepare and store food items in a safe and sanitary manner in the facility's main kitchen.Findings included: Observation of the facility's main kitchen on December 16, 2025, at 8:00 AM revealed the following: There was an accumulation of dust on the stainless-steel hood over the stove. The dry goods storage area contained a white colored heating/cooling unit on the wall near the ceiling. The unit had a build-up of a blackish colored substance on the vents of the unit. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 17, 2025, at 2:00 PM. A review of the facility policy titled Temperature, last reviewed on May 7, 2025, revealed that the temperatures of the food items will be taken and properly recorded for each meal. Observation of the plating service during the tray line in the facility's main kitchen on December 19, 2025, at 11:50 AM revealed that staff were plating the lunchtime meal food trays and placing them in delivery carts so they…

    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 · E2025-12-19 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for two of three residents reviewed with a signed arbitration agreement (Residents 13 and 50).Findings include: Review of an Addendum XIII: Arbitration Agreement (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial), signed by Resident 13's responsible party on March 20, 2025, revealed that the document stipulated that, By signing this Arbitration Agreement, the parties hereby agree that if the parties cannot agree on a neutral arbitrator after thirty days, then (name of arbitrator services company, which the facility utilized), will serve as neutral arbitrator in accordance with the (name of arbitrator services company, which the facility utilized) Rules of Procedure. The agreement afforded the facility the selection 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-19 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for one of four residents reviewed for advance directives concerns (Resident 11).Findings include: Review of Resident 11's electronic medical record (EMR) revealed social services documentation dated October 1, 2025, at 1:37 PM that the interdisciplinary team met with Resident 11's two sons and reviewed her POLST (Physician Orders for Life Sustaining Treatment, a binding medical order that instructs healthcare providers the specific types of medical treatment a resident wishes to receive at the end of life) form that instructed staff to not use artificial hydration and nutrition by tube. Review of Resident 11's physical chart revealed a POLST document signed by Resident 11's son/responsible party on November 12, 2025, that Resident 11 was not to receive hydration or nutrition by tube. Review of Resident 11's active physician orders dated August 12, 2025, revealed instructions to trial nutrition…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-19 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interview it was determined that the facility failed to ensure a resident's rights to secure and confidential personal and medical information in the facility (Main Lobby Area) for one of 16 residents reviewed (Resident 74). Findings include: Observation of the main lobby of the facility on December 18, 2025, at 11:01 AM revealed a binder titled Department of Health Survey Results. The binder contained the results of recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of the binder revealed that the facility placed the full health survey letters and complaint deficiency letters (letters sent to administration after a survey) into the binder. Further review of the binder revealed a complaint deficiency letter and associated Statement of Deficiencies (Form CMS-2567) for a complaint investigation completed on December 27, 2024. The letter noted the name and associated specific resident identifier for Resident 74. The facility failed to ensure…

    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 before2025-12-19 · tag F0641 — isolated
    Ensure 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 observation, resident and staff interview, and clinical record review, it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 16 residents reviewed (Residents 37 and 2).Findings include: Interview with Resident 37 on December 17, 2025, at 10:45 AM revealed that he experienced range of motion (ROM) limitations of his bilateral arms and shoulders due to arthritis (swelling and tenderness of one or more joints, main symptoms are joint pain and stiffness), and he was not participating in any exercise programs or therapy related to range of motion exercises. Observation of Resident 37 on the date and time of the interview revealed that his range of motion limited him to raise his arms only to midway between his waist and head. Clinical record review for Resident 37 revealed diagnoses that included primary osteoarthritis (the protective cartilage that cushions the ends of the bones wears down over time) of left and right shoulders since April 1,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 invite residents to their care plan meetings for one of 16 residents reviewed (Resident 9) and failed to revise a resident's comprehensive care plan for one of 16 residents reviewed (Resident 20).Findings include: The SOM Appendix PP states that Residents and their representative(s) must be afforded the opportunity to participate in their care planning process. During an interview with Resident 9 on [DATE], at 9:52 AM he stated that he had never been invited to his care plan meetings. Resident 9 has a BIMS score (Brief Interview for Mental Status, used to evaluate aspects of cognition such as attention, orientation, and memory recall) of 15 out of 15, indicating normal thinking and memory, no cognitive issues. Clinical record review of Resident 9's chart revealed no documentation of the resident being invited to his care plan meetings. The Nursing Home Administrator and the Director of Nursing were…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide services consistent with professional standards of practice and the resident's comprehensive care plan related to dialysis access care for one of one resident reviewed for dialysis concerns (Resident 6).Findings include: Interview with Resident 6 on December 16, 2025, at 10:45 AM revealed that she leaves the facility three times a week for hemodialysis treatment (due to the inability of the kidneys to filter blood, blood is circulated from the resident, through a machine, for the purpose of removing excess fluids and waste products). Observation of Resident 6 during the interview revealed intravenous access tubing from a dressing on her right upper chest. Resident 6 stated that she needed to have the fistula (shunt, a connection surgically created between an artery and a vein that is used for hemodialysis treatment) in her left arm revised due to a failure to function; and the dialysis center was temporarily using the site to her right upper chest for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain a complete and accurate accounting of a controlled medication for one of three closed resident records reviewed (Resident 71). Findings include: Clinical record review for Resident 71 revealed that the resident was admitted to the facility on [DATE], and discharged due to expiring on October 29, 2025. Review of the Medication Administration Record (MAR) for Resident 71 revealed the resident had orders for morphine sulfate (a controlled substance; a narcotic medication used to relieve pain), which included the following: Morphine sulfate (concentrate) oral solution 20 milligrams (mg) per milliliter (ml) give 0.25 ml by mouth four times a day for generalized pain for five days dated October 21, 2025, at 6:00 PM. Morphine sulfate (concentrate) oral solution 20 mg/ml give 0.25 ml by mouth every two hours as needed for pain / shortness of breath dated October 21, 2025, at 5:15…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to enhanced barrier precautions for one of 16 residents reviewed (Resident 6).Findings include: The facility policy entitled, Enhanced Barrier Precautions, last reviewed May 7, 2025, revealed that enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP refers to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms during high contact resident care activities. EBP apply when a resident has a wound or indwelling medical device. Indwelling medical devices include central lines. EBPs employ targeted gown and glove use (PPE, personal protective equipment) in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Signs are posted 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-27 · 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 a review of select facility policies and procedures, closed clinical record, and staff interview, it was determined that the facility failed to notify a medical provider of a change in a resident's condition for one out of four residents reviewed (Resident CR1). Findings include: A review of the facility policy titled, Change in a Resident's Condition or Status, revealed a policy statement that noted the facility should promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The policy further noted the nurse will notify the resident's attending physician or physician on call when there is a significant change in the resident's physical condition, need to alter the resident's medical treatment significantly, and/or specific instructions to notify the physician of changes in the resident's condition. A review of the facility policy titled, Oxygen Therapy, revealed that a physician must order the oxygen therapy.…

    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 21 citations
  • Potential for harm · E2024-11-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice for three of three residents reviewed for supplemental oxygen concerns (Residents 4, 5, and 15). Findings include: Clinical record review for Resident 4 revealed an active physician's order dated November 29, 2023, for staff to apply supplemental oxygen at two liters per minute (lpm) continuously every shift for shortness of breath. Observation of Resident 4 on November 12, 2024, at 11:01 AM, and November 13, 2024, at 10:03 AM, revealed Resident 4 was in bed with oxygen on and running at three lpm. Resident 4 was not short of breath during the conversation with her. Interview with Resident 4 on November 12, 2024, at 11:01 AM revealed that she recently had an upper respiratory infection and staff increased her oxygen due to her illness. Interview with Employee 1 (assistant director of nursing) on November 15, 2024, at 10:54 AM confirmed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-15 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of select facility policies and procedures, clinical record review, observation, resident and staff interview, and review of personnel records, it was determined that the facility failed to ensure specific competencies necessary to care for resident needs for one of one resident reviewed for intravenous access concerns (Resident 163; Employees 5, 7, 8, 9, 10, and 11). Findings include: The facility policy entitled, Infusion Therapy Responsibilities and Scope of Practice, last reviewed without changes on January 3, 2024, revealed that clinicians administering infusion therapies will practice within the scope of practice for their licensure and applicable state laws, and within their clinical level of competency as established by the facility training and competency evaluation programs. Nursing responsibilities in infusion therapy include performing functions and procedures that are consistent with current standards of care, facility policies and procedures, and that are within the scope of the state nurse practice act. Facility/administration responsibilities in…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-15 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for three of five residents reviewed (Residents 4, 32, and 15). Findings include: Clinical record review for Resident 4 revealed a consultant pharmacy recommendation dated March 10, 2024, requesting Resident 4's physician consider a trial dose reduction of Resident 4's Buspirone (an antianxiety medication) and Venlafaxine (an antidepressant medication). Interview with Employee 1 (assistant director of nursing) on November 15, 2024, at 10:34 AM confirmed that the facility had no evidence that Resident 4's attending physician addressed the March 10, 2024, consultant pharmacist recommendation requesting a review of the possibility of a trial dose reduction, taper, or discontinuation of Resident 4's Buspirone and Venlafaxine. Further review of Resident 4's clinical record on November 14, 2024, revealed there was no evidence the consultant pharmacist reviewed Resident 4'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on November 12, 2024, at 9:15 AM revealed the following: In the freezer there was a bag of French fries, sausage, meatballs, and tater tots opened, not secured, and no open/use by date. There was an open bag of corn with a use by date of November 10, 2024, past the expiration. In the walk-in refrigerator there was a gallon size container of ranch dressing with a use by date of October 19, 2024, past the expiration. There was a gallon of reduced fat and a gallon of whole milk opened with no use by date. In the dry storage room, there were open bags of rice, pasta, and potato flakes with no open/use by dates. Interview with Employee 3 (registered dietician) on November 15, 2024, at 11:31 AM revealed that staff are to date the food when received, then date again with a use by date once…

    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 · D2024-11-15 · 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 and resident interview, it was determined that the facility failed to assist dependent residents with activities of daily living for two of four residents reviewed for activities of daily living concerns (Residents 21 and 53). Findings include: Clinical record review for Resident 21 revealed an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that revealed Resident 21 as totally dependent on the physical assistance of two staff for transferring (moving between surfaces including from bed to wheelchair). Active physician orders for Resident 21 indicated that Resident 21 required a passive mechanical lift to transfer. Observation of Resident 21 on November 12, 2024, at 11:28 AM revealed she was in bed. Observation of Resident 21 on November 13, 2024, at 11:10 AM revealed she was in bed. Interview with Employee 4 (nurse aide) on November 13, 2024, at 11:13 AM 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 · D2024-11-15 · 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 review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered devices or a care planned intervention for two of 17 residents reviewed (Residents 21 and 25); a deep brain stimulator for one of 17 residents reviewed (Resident 25); and a central venous catheter for one of 17 residents reviewed (Resident 163). Findings include: Clinical record review for Resident 21 revealed a physician's order dated February 24, 2023, that instructed staff to apply a left ankle splint at 6:30 AM and remove the splint at 1:30 PM daily. Staff are to perform passive range of motion exercises before applying the splint. A plan of care developed by the facility to address Resident 21's limited physical mobility related to bilateral hand, elbow, and ankle contractures (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-15 · 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practical care to promote pressure ulcer healing for one of two sampled residents with pressure ulcers (Resident 25). Findings include: Current physician orders for Resident 25 revealed an order dated November 13, 2024, that instructed staff to apply Medihoney Wound and Burn Dressing External Paste (a type of topical medication used to treat certain skin wounds) to the right ischium (one of the bones of the pelvis) topically every shift for open skin areas on the buttocks and groin and to mix with zinc equal parts and specified half an ounce. Further review of the physician orders for Resident 25 revealed a second order dated October 24, 2024, that instructed staff to apply Zinc Oxide External Paste 40 percent topical to open skin areas every shift for open wound areas to the groin and buttocks and add equal parts to the Medihoney and specified half an ounce. A skin/wound note for Resident 25 dated November 11, 2024, at 2:55 AM revealed the resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure controlled substance medication accountability and security on one of two nursing units (second floor, Residents 12 and 35, Employee 6). Findings include: The facility policy entitled, Controlled Substances, last reviewed without changes on January 3, 2024, revealed that the facility would comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. An individual resident controlled substance record must be made for each resident who will be receiving a controlled substance (one prescription per page). The information on the record must include number on hand, time of administration, and signature of nurse administering the medication. The charge nurse on duty will maintain 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 clinical record review, observation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for 1 of 17 residents reviewed (Resident 45). Findings include: Clinical record review for Resident 45 revealed a physician's order dated October 11, 2024, that instructed staff to weigh the resident weekly. Dietary documentation dated October 11, 2024, at 4:27 PM revealed that Resident 45 had lost weight. An intervention from dietary included adding weekly weights to monitor the resident. The weights documented in Resident 45's electronic health record included the following: 10/7/24: 126.0 pounds (lbs) 11/7/24: 124.5 lbs 11/11/24: 125 lbs There was no evidence in Resident 45's clinical record that indicated the weekly weights ordered by the physician and recommended by the dietary staff were completed. The above information was reviewed in a meeting with the Nursing Home Administrator and Employee 1, assistant director of nursing, on November 14, 2024, at 2:24 PM. Employee 1 reported she will attempt to obtain…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for two of 17 residents reviewed (Residents 25 and 163). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility policy titled, Enhanced Barrier Precautions, last reviewed without changes on January 3, 2024, revealed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, the facility failed to assess and implement interventions to promote wound healing for one of three residents reviewed (Resident 3). Findings include: Clinical record review for Resident 3 revealed he was admitted to the facility on [DATE], with an unstageable pressure ulcer (a pressure injury that is not stageable due to coverage of wound by slough or stringy material and/or eschar or dead tissue) to the right buttocks. Review of a wound consultant service note for Resident 3 dated February 16, 2024, revealed the resident had a 5.5 cm (centimeter) length x 5.5 cm width x 0 cm depth unstageable pressure ulcer of the right buttocks. The ordered treatment recommendations were to cleanse the area with Normal Saline (a non-toxic fluid like the components of body fluid that does not damage healing tissues), apply collagen with silver (a wound treatment to promote healing and prevent infection) to the base of the wound, and secure with bordered foam…

    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 · E2024-01-19 · tag F0656 — failed to write and follow a full care plan — pattern
    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 develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for four of 16 residents reviewed (Residents 2, 44, 5, and 47). Findings Include: Interview with Resident 2 on January 17, 2024, at 11:54 AM revealed that he has a broken back and that he gets severe pain at times. He said that he will ask for pain medication when this happens. He also indicated that it is not every day and usually only one or two times a week. Review of Resident 2's medication administration record (a form used to document medications given to the resident) revealed that he was provided pain medication six times in November 2023, four times in December 2023, and nine times in January 2024. Review of Resident 2's clinical record revealed that there was no current plan of care for his pain. Clinical record review for Resident 47 revealed a skin and wound note dated January 12, 2024, at 12:56 PM. The note indicated that Resident 47 had a Stage III sacral…

    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 · Ecited before2024-01-19 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 observation and staff interview, it was determined that the facility failed to secure medications and biologicals on one of two nursing units (First Floor Nursing Unit). Findings include: Observation of the first-floor nursing unit on January 18, 2024, at 8:51 AM revealed the medication room door with keys inserted into the doorknob. This surveyor was able to enter the room using an easy turn of the keys and push the door open. Medications were on the counter to include prescription intravenous antibiotics, two Flonase nasal sprays (treats allergies), Ventolin inhaler (used to treat respiratory problems), Acidophilus (a probiotic) and Alka seltzer. Above the sink was an unlocked cabinet that contained multiple bottles of over-the-counter medications that including but not limited to Acetaminophen (pain reliever), Melatonin (sleep aid), Magnesium, Vitamin D, Zinc, Iron, Diphenhydramine (treats allergies) and Deep-Sea Nasal Spray (treats nasal dryness). The medication room continued to be left unattended and accessible to non-licensed staff, residents, and visitors until 9:04…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thoroughly investigate and report an allegation of misappropriation of property to the State Survey Agency for one of one resident reviewed (Resident 16). Findings include: Clinical record review for Resident 16 revealed a social service progress noted dated November 27, 2023, at 3:31 PM that indicated Resident 16 alleged that a couple of days before her hospitalization a tall man came to her and told her that she did not need her watch anymore and ripped it off her hand and pointed to a resident sitting down in the hallway and stated it was him. A social service progress note dated November 24, 2023, at 3:21 PM revealed that Resident 16 was missing a watch with a black face and tan strap. Her room was searched, and no watch was found. The note indicated that the hospital had no record of a watch being in her possession during her recent stay. The note also indicated that Resident 16's story changed concerning the missing item. Social Services notified Resident 16's sister…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-19 · tag F0641 — isolated
    Ensure 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 clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of 16 residents reviewed (Residents 33 and 55). Findings include: Review of Resident 33's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 7, 2023, and November 20, 2023, that indicated the facility assessed her as having moisture associated skin damage (MASD, inflammation and erosion of the skin caused by excessive moisture). Review of Resident 33's wound assessments dated October 27, 2023, November 3, 2023, November 10, 2023, November 17, 2023, and November 24, 2023, indicated that the wound care consulting company described Resident 33's wound as being full thickness skin loss, which would be considered a Stage III (wound that involves full thickness loss of the skin potentially extending into the subcutaneous tissue) pressure ulcer according 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-19 · 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 clinical record review and staff interview, it was determined that the facility failed to assess and implement interventions regarding weight gain for one of six residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record revealed he had a diagnosis of congestive heart failure since his admission to the facility in 2019. Documentation indicated that nursing staff weighed him on July 6, 2023, to be 164 pounds. Nursing staff weighed him on January 10, 2023, to be 183 pounds, which would be a 11.59 percent significant weight gain in six months. Resident 4's current body weight would put him into the overweight category for body mass index. There was no documented evidence in Resident 4's clinical record to indicate that nursing staff assessed Resident 4 for edema related to his diagnosis of congestive heart failure. A nutritional risk assessment dated [DATE], and again on December 6, 2023, indicated that Resident 4's usual body weight was between 172 and 178 pounds. A dietary…

    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 · D2024-01-19 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 40). Findings include: Clinical record review for Resident 40 revealed the facility admitted her on October 25, 2018, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 40's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 2, 2023, indicated that the facility assessed Resident 40 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 40's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of two nursing units (First Floor and Residents 41 and 213). Findings include: Clinical record review for Resident 41 revealed that she was on transmission-based precautions (TBP) related to a diagnosis of COVID-19. Observations of Resident 41's room on January 17, 2024, at 11:25 AM revealed a sign indicating that she was on droplet precautions (preventative steps taken by healthcare team members and staff to prevent the spread of an infection that is transmitted by coughing, sneezing, talking or close contacts with an infected person). The sign indicated that an N-95 mask (a mask that protects you from breathing in small particles in the air) is to be worn when entering the room. Observation of Employee 5 (Housekeeper) at 11:25 AM on January 17, 2024, revealed she was in Resident 41's room with a surgical mask on. Interview with Employee 6 (Housekeeping supervisor) at 11:35 AM on January 17, 2024, revealed that Employee 5…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-06 · 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

    Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and homelike environment on one of two nursing units (First Floor, Residents 1 and 2), and facility entrance/exit area. Findings include: An observation of Resident 1's room on December 6, 2023, at 11:45 AM revealed a small section of missing floor tile to the left of the residents heating/cooling unit under the window. A built-out section of lower wall to the right of the unit extending to the closet wall was completely pulled away hanging from the wall exposing the area behind it. Concurrent observation of Resident 1's bathroom revealed several blackened areas on the tile floor and under the bathroom sink, with brown and black buildup observed around the base of the toilet. An observation of Resident 2's room on December 6, 2023, at 11:55 AM revealed black buildup/debris on the flooring where the floor meets the cove base along the front of the resident's room extending to the bathroom door area. The bathroom was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-01-19 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice that included all the written components to the resident and/or the resident's responsible party upon transfer to the hospital for four of five residents reviewed (Residents 5, 16, 33, and 39). Findings include: Review of Resident 33's clinical record revealed that she was transferred to the hospital on December 6, 2023. The transfer notice provided by the facility to Resident 33's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office. Review of Resident 16's clinical record revealed that she was transferred to the hospital on November 12, 2023. The transfer notice provided by the facility to Resident 16's responsible party regarding her transfer to the hospital did not include all 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
  • No harm found · C2024-01-19 · 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 and staff interview, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include: Observation on January 17, 2024, at 8:50 AM revealed that the facility's two main dumpsters in the parking lot were overfilled, and the lids were not able to close. There were at least four bags of garbage laying on the ground between the two dumpsters. Interview with Employee 2, dietary manager, on January 17, 2024, at 9:40 AM acknowledged the above observations. Subsequent interview with Employee 3, director of maintenance, on January 17, 2024, at 9:45 AM revealed that the facility does not have an alternate means of proper disposal of garbage if their dumpsters are full. 29 Pa. Code 201.18 (b)(1) Management

    Nutrition and Dietary 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

$10,033 in federal fines across 1 penalty.

  • $10,033 — penalty dated 2024-01-19

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 PRIORITY HEALTHCARE GROUP — 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 →

RatingThis homeChain avg
Overall 3 of 53.0≈ chain avg
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 52.9+1.1 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 11 homes this chain runs (chain average 3.0★, 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 / managerTypeRoleShareSince
HASHTAG HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/01/2017
BLGLPA LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST14%since 10/27/2017
FAIR OAKS FAMILY HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST14%since 01/28/2020
HASHTAG-EL-HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST17%since 10/27/2017
SAMARA HOLDINGS COMPANY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST17%since 01/28/2020
STRAWBERRY HILL HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST17%since 01/28/2020
SEBBAG, GABRIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 10/27/2017
SCHIOWITZ, MARCIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
CLINICAL CONSULTING SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
PRIORITY CARE GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019
SUMMATION FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
MONAHAN, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2017
PAGANA, CHARLESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/16/2025
GLATZER, AKIVAIndividualGENERAL PARTNERSHIP INTERESTsince 10/27/2017
GAMZEH, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/04/2025
GREATOREX, TINAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/04/2025
GPH SUNBURY LPOrganizationADP OF THE SNFsince 02/01/2017

CMS files one row per role, so the 23 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

10 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.

$6.2M
Net patient revenuemost recent cost report
-3.6%
Operating marginrevenue minus expenses
$1.1M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 85%Medicare 6%Other / private 9%

About 85% 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 $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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.

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

$287per resident / day
operating cost
$8,718per month
≈ monthly operating cost
$277per 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 395482. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, 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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