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Sunbury Skilled Nursing And Rehabilitation Center

901 Court Street, Sunbury, PA 17801 · For profit - Corporation · 126 certified beds · (570) 286-7121 Medicare & Medicaid certified

Call the home — (570) 286-7121 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0744)
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)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 21% 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) 3 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
512 Market St · (570) 286-9878 · 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

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 3 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 increased18.1%16.8%15.4%worse
Long-stay residents who lose too much weight5.9%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 infection1.3%1.5%2.0%better
Long-stay residents with depressive symptoms36.7%10.8%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.7%3.1%3.3%worse
Long-stay residents whose ability to walk worsened21.0%17.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.8%20.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers3.9%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control26.5%25.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table23.7%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.7%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine94.9%68.7%79.4%better
Short-stay residents rehospitalized after admission25.7%22.5%22.6%worse
Short-stay residents with an outpatient ER visit6.1%9.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.061.621.67worse
Long-stay outpatient ER visits per 1,000 resident days1.001.181.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

§ 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.

52.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.4%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 60 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.4%CMS range 41.6–63.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 7.0–12.410.7%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 discharge50.0%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 discharge45.0%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 discharge45.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.2%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 worsened4.9%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 hospitalization6.0%CMS range 3.3–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 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

0.83
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.38
Aide hours/ resident / day
3.90
Total nurse hours/ resident / day
0.61
RN hoursweekends
52.1%
Total nursing turnover
27.8%
RN turnover

How full it usually is: this home is certified for 126 beds and averages 107.3 residents a day — about 85% occupied, or roughly 19 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.60 hrs/resident/day on weekends vs 4.02 on weekdays — 11% thinner on weekends. RN hours go from 0.92 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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

11
deficiencies at the latest standard inspection (2026-05-08)
8
at the previous standard inspection (2025-06-13)

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

Inspection deficiencies

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

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · E2026-05-08 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and resident and staff interview it was determined that the facility failed to provide a written notice of transfer that included all the necessary contents to residents' responsible parties at the time of transfer for three of four residents reviewed for hospitalizations (Residents 1, 2, and 79); and failed to provide timely written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer that included all the necessary contents for two of four residents reviewed for hospitalizations (Residents 2 and 79).Findings include: Interview with Resident 2 on May 5, 2026, at 1:02 PM revealed that it was necessary for him to go to the hospital because of his indwelling urinary catheter. Clinical record review for Resident 2 revealed nursing documentation dated November 17, 2025, at 12:21 PM that Resident 2's Foley (indwelling urinary catheter, flexible tubing inserted through the penis into the bladder to drain urine) tubing and urinary collection bag presented with frank blood draining, Resident 2 complained of lower…

    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 · Ecited before2026-05-08 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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

    Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement range of motion devices for two of four residents reviewed for range of motion concerns (Residents 3 and 12).Findings include: Clinical record review for Resident 3 revealed a diagnoses list that included contracture (A medical condition characterized by the shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments. This leads to a loss of elasticity and a reduced range of motion in the affected area, which can significantly impact daily activities), left hand, and contracture, right hand, since November 21, 2025. An active physician order dated February 26, 2026, directed the use of, Restorative splints, No directions specified for order. Documentation Survey Report data (electronic documentation completed by nurse aide staff to attest to the provision of care) dated May 2026 included the intervention, Restorative Program Splint/brace assistance (number one): See care plan/kardex for program description. Review of Kardex…

    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 · Ecited before2026-05-08 · 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 store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility.Findings include: Initial tour of the facility's main kitchen with Employee 19, Dietary Manager, on May 5, 2026, at 9:09 AM revealed the following: A package of waffles in a freezer with no evidence of a date of when they were placed there, opened, or needed to be used by. A package of frozen fish in a freezer. The written date on the item was smudged and unreadable. An open box of salt that was stored on a shelf with spices. The package indicated to use within three years of opening. The item was not dated with an open date. The surface of the shelf was covered with a granule-like substance. There were four packaged rolls of ground beef in a stainless-steel pan located on the bottom shelf of a refrigerator. Employee 19 indicated they were thawing for use later. These items were located next to four, one gallon plastic containers of milk. One of the containers of milk…

    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 · E2026-05-08 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 and staff interview it was determined that the facility failed to ensure complete and accurate clinical records for four of 26 residents reviewed (Residents 3, 5, 10, and 83). Findings include: Clinical record review for Resident 5 revealed that the Immunization tab in the resident's electronic health record (EHR) information indicated that Employee 8 (registered nurse/infection control prevention coordinator) confirmed on October 21, 2025, that education regarding the risks and benefits of the influenza vaccine was provided to Resident 5; and that he refused the immunization. Review of a Patient/Resident Influenza Vaccine Informed Consent document signed by Employee 8 on October 21, 2025, indicated that staff obtained verbal consent to administer the influenza vaccine to Resident 5. Review of Resident 5's Medication Administration Record (MAR, electronic documentation of the administration of medications by licensed staff) dated October 2025 revealed that staff documented Resident 5's refusal of the influenza immunization on October 7, 2025, at 6:27…

    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 · E2026-05-08 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and review of available employee immunization records it was determined that the facility failed to maintain documentation of the COVID-19 vaccination status of each staff member for four of four employees reviewed (Employees 4, 5, 6, and 7).Findings include: The surveyor requested documentation of the facility's tracking of employees' current COVID-19 immunization status during an interview with the Director of Nursing and the Nursing Home Administrator on May 6, 2026, at 2:00 PM; with the Nursing Home Administrator on May 7, 2026, at 6:10 PM; and with Employee 8 (registered nurse/infection control prevention coordinator) on May 8, 2026, at 10:25 AM. Interview with Employee 8 on May 8, 2026, at 10:56 AM indicated that the facility maintains staff immunization documentation in an electronic record keeping system. Employee 8 indicated that once the surveyor provided the names of employees for review, she would be able to access the records for those staff. Interview with Employee 4 (housekeeping/assistant manager) on May 8, 2026, at 11:54 AM revealed that she…

    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 · D2026-05-08 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, review of select facility policies and procedures, observation, and resident and staff interviews. it was determined that the facility failed to promote resident choices about aspects of his or her life in the facility that are significant to the resident regarding food brought in from home for one of 26 sampled residents (Resident 65). Findings include: The policy entitled Food Brought in for Patients/Residents, last reviewed without changes August 27, 2025, revealed food and beverages may be brought in from outside the facility for individual patients/residents but must not be offered to other residents. Food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner. Food may be reheated in microwaves by staff only. Interview with Resident 65 on May 8, 2026, at 10:22 AM revealed his daughter brought him some homemade gluten free spaghetti and the facility would not let him eat it stating they will not reheat food brought in from home. Interview with Employee 20 (licensed practical nurse) on May 5, 2026, at…

    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 · D2026-05-08 · 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, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 26 residents reviewed (Resident 12).Findings include: Clinical record review for Resident 12 revealed her diagnoses list included left hand contracture (A medical condition characterized by the shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments. This leads to a loss of elasticity and a reduced range of motion (ROM) in the affected area, which can significantly impact daily activities.) since September 24, 2025. Physician orders for Resident 12 included an active physician order dated June 14, 2025, for staff to apply inter-dry (a soft fabric used for skin fold management; it removes moisture from skin-to-skin contact areas) to Resident 12's left palm prior to splint application for prevention/protection every day shift. Review of Resident 12's Treatment Administration Record (TAR,…

    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 · D2026-05-08 · 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, observation, and staff interview it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a cardiac pacemaker for one of 26 residents reviewed (Resident 1). Findings Include: Clinical record review for Resident 1 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart), sick sinus syndrome (a malfunctioning of the heart that impacts the heart's natural pacemaker node), and atrial fibrillation (an irregular heart rhythm). Medical provider documentation for Resident 1 dated May 5, 2026, at 1:00 AM revealed that the resident has a pacemaker. Cardiology documentation dated September 5, 2025, at 3:39 PM revealed that Resident 1 had a leadless pacemaker implanted in May 2022. Review of Resident 1's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 6,…

    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 · D2026-05-08 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, review of facility documentation, observation, and resident and staff interview, it was determined that the facility failed to appropriately assess a side rail for entrapment zone risks and obtain informed consent for side rail use for one of six residents reviewed for accident hazards (Resident 69).Findings include: Clinical record review for Resident 69 revealed a diagnosis list that included muscle weakness and hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated February 10, 2026, revealed that facility staff assessed Resident 69 as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment. Observation and concurrent interview with Resident 69 on May 6, 2026, at 10:30 AM revealed a side rail that was attached to the resident's right side of the bed. The side…

    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 · D2026-05-08 · tag F0726 — failed to have competent, trained nursing staff — isolated
    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 facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with a PICC line, and catheter care, for four of four employees reviewed for competencies (Employees 1, 22, 23, and 24).Findings include: A review of the facility documentation revealed that the facility had a total of five residents with indwelling catheters (insertion of a tube into the bladder to remove urine), and one resident with a discontinued PICC line (peripherally inserted central catheter, a long flexible tube inserted into a vein in the arm that reaches a large central vein near the heart). A request for nursing staff competencies for PICC line and catheter care revealed the facility was unable to provide these competencies for Employees 1 and 24 (LPN, licensed practical nurse), and Employees 22 and 23 (RN, registered nurse). Interview with Employee 28 (registered nurse educator) on May 8, 2026, at 1:21 PM confirmed that the facility…

    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
Show the remaining 19 citations
  • Potential for harm · D2026-05-08 · 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

    Based on observations and resident and staff interviews, it was determined that the facility did not provide food in accordance with resident preferences for one of 26 residents reviewed (Resident 47).Findings include: The facility policy entitled Dining and Food Preferences, last reviewed without changes August 27, 2025, revealed individual dining, food, and beverage preferences are identified for all residents. The dining services director, or designee will interview the resident or resident representative to complete a food preference interview within 72 hours of admission. The purpose of this interview will be to identify individual preferences for dining location, mealtimes, including times outside of the routine schedule, and food and beverage preferences. The food preference interview will be entered into the medical record. Food and fluid preferences will be entered in the menu management software system. Clinical record review revealed the facility admitted Resident 47 on April 1, 2026. Interview with Resident 47 on May 5, 2026, at 2:35 PM revealed that Resident 47 told…

    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 · Ecited before2025-06-13 · 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

    Based on observation and staff interview, it was determined that the facility failed to provide a clean environment on one of two nursing units (Second Floor, Resident 108), and maintain facility equipment in the facility's main kitchen. Findings include: Observation on June 10, 2025, at 12:08 PM of Resident 108's room revealed a two-tiered cart beside the bed that housed a humidification machine on the top rack, a cardboard box, a stack of inverted plastic cups, and a jug of water on the bottom rack. The cart appeared soiled with dust and debris and had a dried white substance splashed on it. Observation of Resident 108's room on June 11, 2025, at 9:59 AM revealed the humidification machine was in use and the cart still appeared soiled with dust and debris and the dried white substance remained. Interview with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 2:28PM reviewed the above noted items regarding Resident 108. Observation in the facility's main kitchen on June 10, 2025, at 9:07 AM revealed multiple metal shelves inside several two-door storage…

    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 · D2025-06-13 · 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 review of select facility policy and procedures, observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure and confidential personal and medical records on the ground floor of the facility and one of two nursing units (First Floor Nursing Unit North Wing). Findings include: A review of the facility policy titled, Safeguarding and Storage of Health Information Records, last reviewed on August 21, 2024, revealed that the company will maintain reasonable administrative, technical, and physical safeguards to protect the privacy of protected health information (PHI) from use or disclosure that is a violation of federal and/or state regulations. The purpose of the policy was noted to limit unauthorized access of PHI. Further review of the facility policy revealed a section titled Procedure, that noted procedures such as the following: protect all health information records from damage, loss, destruction, or unauthorized use; limit viewing access by unauthorized personnel as well as visitors by returning records to their…

    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 before2025-06-13 · 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

    Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for one of 24 residents reviewed (Resident 317). Findings include: Clinical record review for Resident 317 revealed a diagnosis list that included atrial fibrillation (an irregular and sometimes rapid heart rhythm that can lead to complications such as stroke and heart failure) and essential hypertension (high blood pressure). Review of Resident 317's current care plan revealed the resident is at risk for cardiovascular symptoms or complications related to low blood pressure due to medications with parameters in place. A review of the current physician orders for Resident 317 revealed an order dated March 1, 2025, for Metoprolol Succinate ER Extended Release (a medication that is used to treat high blood pressure and/or heart rate) 25 milligrams (mg) give half a tablet by mouth one time a day for hypertension. Hold for a systolic blood pressure (SBP, the top number of a blood pressure reading where…

    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 before2025-06-13 · 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 staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of one resident reviewed receiving hemodialysis (Resident 15). Findings include: In an interview and observation of Resident 15 on June 10, 2025, at 11:42 AM the resident indicated he attended dialysis outside the facility three days a week and that his access site was in his arm. Concurrent observation of Resident 15's room did not reveal any emergency supplies used to control bleeding such as sterile gauze, hemostat (a tool used to control bleeding), needleless connector, or tape in the resident's room readily available should the resident start bleeding from his dialysis access site. With the resident's permission to look inside his closet there was also no evidence of any emergency supplies in Resident 15's closet. Clinical record review for Resident 15 revealed the resident was receiving hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood 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 · D2025-06-13 · 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

    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 and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 18). Findings include: Clinical record review for Resident 18 revealed that the facility admitted her on May 31, 2014. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added to her clinical record on October 1, 2022. A review of Resident 18's significant change Minimum Data Set (MDS, a form completed at specific intervals to determine care needs) assessment dated [DATE], indicated that the facility assessed Resident 18 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 18's current care plan entitled, Cognitive loss as evidenced by forgetfulness related to dementia last revised…

    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 · D2025-06-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 ensure a medication error rate below five percent (First Floor Nursing Unit North Wing; Resident 22). Findings include: The facility's medication error rate was 7.14 percent based on 28 medication opportunities with two medication errors. Observation of Resident 22's medication administration pass on June 12, 2025, at 9:05 AM revealed that Employee 4, licensed practical nurse (LPN), prepared the medications prior to administration. Employee 4 went to Resident 22's room and placed one drop of Brimonidine Tartrate-Timolol Ophthalmic Solution 0.2-0.5% (a medication administered via eye drops to lower the pressure in the eyes known as intraocular pressure) into each of the resident's eyes. Review of Resident 22's clinical record revealed a physician's order dated March 6, 2025, that noted Brimonidine Tartrate-Timolol Ophthalmic Solution (0.2-0.5%) instill one drop in the right eye two times a day for glaucoma (an eye condition that can lead to vision loss or blindness and is often associated 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · 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 observation and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (First Floor Nursing Unit) and failed to ensure the security of a resident's prescription for a controlled substance one of one nursing units reviewed (Second Floor Nursing Unit, Resident 45). Findings include: Observation during the medication pass on the North Hall of the First Floor Nursing Unit on June 12, 2025, at 9: 15 AM revealed a medication cart being utilized by Employee 4, licensed practical nurse. Observation of the medication cart revealed the following: There were several unsecured and unidentified medication tablets found in the bottom of the drawers that included: a brown oblong tablet, a pink colored oblong tablet, and a white colored oblong tablet. A drawer of the medication cart had a container of individually wrapped supplemental vitamin chews that contained a pink colored oblong medication tablet and a yellow colored oblong medication tablet. A concurrent interview with Employee 4 revealed that it 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-15 · 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 review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide comprehensive skin assessments that are consistent with professional standards of practice, to promptly identify changes to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 1). This deficiency is cited as past noncompliance Findings include: A review of the facility policy titled, Skin Integrity and Wound Management, dated October 15, 2024, revealed that, a comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin and wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revision to the plan of care as needed. Notify Medical Director, Director of Nursing, and Administrator, if…

    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 before2024-09-10 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for each resident.
    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 assist residents to obtain routine dental care for four of eight residents reviewed (Residents 1, 2, 6, and 7). Findings include: Clinical record review for Resident 1 revealed documentation by the facility's consultant dental hygienist provider dated September 8, 2023, that recommended prophylactic adult dental cleaning every six months; and that the next scheduled visit would be March 8, 2024. Documentation by the facility's consultant dentist provider dated October 10, 2023, November 9, 2023, February 27, 2024, and March 21, 2024, continued to indicate that the treatment plan for Resident 1 was adult prophylactic cleaning every six months and that the next scheduled visit would be March 8, 2024. Resident 1's medical record contained no evidence that she received a dental cleaning on March 8, 2024. Interview with the Nursing Home Administrator, the Director of Nursing, Employee 1 (medical records), and Employee 2 (social worker), on September 10, 2024, at…

    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 · Fcited before2024-07-10 · 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 — 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/storage equipment in a safe and sanitary manner in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on July 7, 2024, at 9:28 AM revealed a large gray garbage can in the dishwashing area. The exterior lid and sides were covered in dried food and liquid spills. The wall behind the garbage can was covered in dried food and liquid spills. Dried food splatter was observed over the dish machine area on the ceiling. The ceiling beside the dish machine area was observed with visible dust hanging from the light covers, on the ceiling, and surrounding the ceiling vent. A metal cart was observed in the kitchen tray line area along the wall with multiple labels of different kinds of cereal. Plastic trays were observed on the cart beside each label with several bowls full of cereal. Cereal was observed scattered on the trays around the bowls. A cart near the steam table contained dust and debris around and under the plate pellet…

    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 · Ecited before2024-07-10 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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

    Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding a splint recommended by therapy to improve range of motion for one of five residents reviewed (Resident 98). Findings include: During an interview and observation with Resident 98 on July 8, 2024, at 9:50 AM revealed that she had contractures of her bilateral hands. Resident 98 stated staff are supposed to apply splints to her hands at night, but they usually forget or don't know how to apply the splints. Interview with Employee 4 (rehab therapy director) on July 10, 2024, at 12:28 PM revealed that he recommended staff apply Resident 98's bilateral splints on May 24, 2024. Employee 4 provided documentation dated May 24, 2024, titled Daily Interdisciplinary Eagle Room Report, noting staff is to apply a comfy grip orthotic splint to Resident 98's left upper extremity and resting hand orthotic splint during the nighttime hours. Further review of Resident 98's clinical record revealed no documentation that staff…

    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 before2024-07-10 · 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 orderly environment on one of two nursing units (First Floor Nursing Unit, Residents 11, 30, 74, and 91). Findings include: Observation of the facility on July 7, 2024, at 10:52 AM revealed environmental concerns on the First Floor Nursing Unit. There was a smell of urine upon entry to the floor with the urine smell becoming very strong when nearing Resident 91's room and continued onto Residents 74 and 11's room. This strong/intense smell of urine continued to be noted on the south hall of the First Floor Nursing Unit, especially around Resident 91, 11, 74, and 101's rooms, on July 8, 2024, at 9:50 AM, and July 10, 2024, at 11:02 AM. Upon entry to Resident 91's room on July 7, 2024, at 10:53 AM, July 8, 2024, at 9:52 AM, and July 10, 2024, at 11:06 AM, an intense, extremely strong smell of urine was noted, especially by the resident's bed and nightstand area, to the point of causing this surveyor's eyes and nose…

    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 · D2024-07-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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, and staff interview, it was determined that the facility failed to implement appropriate treatment and services to prevent potential complications of a feeding tube for one of two residents reviewed (Resident 107). Findings include: The facility policy entitled, Medication Administration: Enteral Tubes, last reviewed without changes on August 23, 2023, revealed that the nursing care center will assure the safe and effective administration of enteral formulas and medications. The policy indicated that enteral tubes (a tube inserted into the stomach for the purpose of providing nutrition or medications) would be flushed with at least 15 milliliters (ml) of water before administering any medications and after all medications have been administered. Clinical record review of Resident 107's current orders revealed that her oral medications were to be administered through her Percutaneous endoscopic gastrostomy (PEG tube, a tube passed into the stomach through the abdominal wall to provide a means 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 before2024-07-10 · 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

    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 care consistent with professional standards of practice for one of one resident reviewed for dialysis concerns (Resident 31). Findings include: Interview with Resident 31 and her husband on July 7, 2024, at 12:12 PM revealed that she goes to dialysis (a process of purifying the blood of a person whose kidneys are not working normally) Tuesday, Thursday, and Saturday. Clinical record review revealed the facility admitted Resident 31 on March 7, 2024. A review of the nursing admission summary dated [DATE], at 5:44 PM revealed Resident 31 is a hemodialysis patient with her dialysis days being Tuesday, Thursday, and Saturday. Documentation further revealed that Resident 31 has an AV (arteriovenous) fistula (one access type that is created by connecting the artery to the vein under the skin) in her left upper arm with positive bruit and thrill (indicates the fistula is functioning properly) noted.…

    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 · D2024-07-10 · 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 observation, clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of two residents reviewed for mood/behavior (Resident 7). Findings include: Clinical record review revealed the facility admitted Resident 7 on January 26, 2023, and added a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) on November 8, 2023. Further clinical record review for resident 7 revealed the resident is documented as having frequent episodes of hallucinations, delusions, paranoia, yelling out, and refusing care. In an interview and observation with Resident 7 on July 7, 2024, at 12:10 PM the resident was observed lying calmly in bed and had just finished his lunch. The resident was able to carry on a conversation conveying accurate information informing the surveyor 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 before2024-07-10 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    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 assist a resident to obtain routine dental services for one of two residents reviewed for dental concerns (Resident 2). Findings include: Interview with Resident 2 on July 7, 2024, at 9:49 AM revealed that she could not remember when she last saw the dentist. Clinical record review for Resident 2 revealed that the facility admitted her on November 3, 2019, with payment sources that included the state Medicaid benefit. Review of Resident 2's request for service dated November 21, 2019, revealed she requested to receive dental services. Further review of Resident 2's clinical record revealed she last saw the dentist on January 20, 2022. A review of this progress note revealed that Resident 2 was due for her next visit for prophylactic dental cleaning in six months. There were no further dental visits. The facility provided documentation that Resident 2 was offered a prophylactic cleaning on January 9, 2023, which she refused. An interview with the Director of Nursing and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-06-13 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 ensure the results of the most recent survey were posted in a place readily accessible to residents, family members, and legal representatives in the main lobby of the facility and on one of two nursing units (First Floor Nursing Unit). Findings include: Observation of the main lobby of the facility on June 10, 2025, at 2:31 PM and the First Floor North Nursing Unit resident lounge at 2:40 PM revealed a binder that should contain the results of the most recent survey 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 binders revealed that the facility placed the full health survey letters and complaint deficiency letters (letters sent to administration after a survey) into the binder; however, did not place the Statement of Deficiencies (Form CMS-2567) as required. The deficiency letters placed in the binders also noted the specific resident identifiers and associated resident names used for any…

    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 · B2024-07-10 · 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 Office of the State Long-Term Care Ombudsman of a transfer to the hospital for 2 of 12 residents reviewed (Residents 14 and 114). Findings include: Clinical record review for Resident 14 revealed the resident was transferred to the hospital and admitted on [DATE], for kidney stones. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 14's transfer to the hospital. Closed clinical record review for Resident 114 revealed the resident was admitted to the facility on [DATE], and sent to the hospital and admitted on [DATE], due to physical aggression. Resident 114 did not return to the facility. There was no evidence the facility notified Office of the State Long-Term Care Ombudsman of Resident 114's transfer to the hospital/discharge. In an interview with Employee 3, admissions coordinator, on July 9, 2024, at 10:37 AM she indicated 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 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

No federal fines in the current CMS record.

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 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 3 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
WHITMAN, ARNOLDIndividual5% 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
LAUER, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/03/2024

CMS files one row per role, so the 15 rows in the source record cover these 14 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.

$12.2M
Net patient revenuemost recent cost report
-8.7%
Operating marginrevenue minus expenses
$2.8M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 86%Medicare 4%Other / private 10%

About 86% 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 $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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 2024. 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

$321per resident / day
operating cost
$9,754per month
≈ monthly operating cost
$295per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 395512. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-08, 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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