Tremont Health & Rehabilitation Center
44 Donaldson Road, Tremont, PA 17981 · For profit - Limited Liability company · 180 certified beds · (570) 695-3141 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- about 20% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.4% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.2% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.1% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.3% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 26.6% | 10.8% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.8% | 17.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 23.2% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.2% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.5% | 25.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.9% | 17.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 57.0% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.8% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.6% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.66 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.67 | 1.18 | 1.80 | better |
† 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.
37.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 52 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 37.1%CMS range 26.4–46.7 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.7–14.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 73.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 71.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 90.9% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.8–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 180 beds and averages 159.8 residents a day — about 89% occupied, or roughly 20 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.15 hrs/resident/day on weekends vs 3.55 on weekdays — 11% thinner on weekends. RN hours go from 0.62 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · E2026-04-10 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of three nursing units. (Nursing Units B, C and E )Findings include: Observations on April 7, 2026, from 10:30 a.m. to April 9, 2026, at 1:00 p.m., revealed the following: The privacy curtain in room [ROOM NUMBER] was stained. In rooms 302, 304, 306, and 312 the air conditioning units were dirty and had a thick layer of dust. The linen closet floors were dusty and dirty under the last shelf. On Unit B, two mechanical lifts and one sit to stand lift were observed and had thick hair and debris wrapped around the wheels. On Unit B, a beverage cart had thick hair and debris wrapped around the wheels two days in a row. The beverage carts were brought to the unit with beverages prior to the meal delivery carts and taken back to the kitchen after the meal. In the nourishment room on Unit B, inside the microwave there was a large amount of dried orange liquid staining on the turntable dish 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.
- Potential for harm · Dcited before2026-04-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and observation, it was determined that the facility failed to provide care and services to one of 35 sampled residents in a manner that maintained each resident's dignity. (Resident 23)Findings include: Clinical record review revealed that Resident 23 had diagnoses that included bipolar disorder and depression. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required assistance with self-care including eating. A review of the care plan identified that the resident was at nutritional risk and required restorative training and skill practice for eating and swallowing. There was an intervention for staff to provide her with assistance during meals. Observation on April 7, 2026, at 12:10 p.m. through 12:45 p.m., revealed that staff had delivered Resident 23's lunch meal to her in the dining room. The resident received puree texture food on a regular plate that was on top of a base. The resident attempted to eat the pureed meal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-10 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and facility documentation review, it was determined that the facility failed to report an alleged violation of verbal abuse for one of 36 sampled residents. (Resident 140)Findings include:Review of the facility policy entitled, Pennsylvania Resident Abuse, last reviewed March 24, 2026, defined verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, regardless of their age or ability to comprehend. Review of the policy further revealed that the Administrator or Abuse Coordinator would notify the applicable local and state authorities of abuse allegations.Clinical record review revealed that Resident 140 had diagnoses that included major depressive disorder and diabetes. The Minimum Data Set assessment dated [DATE], indicated that the resident had no cognitive impairment. On March 18, 2026, a nurse noted that Resident 140 notified staff that someone had left mean notes in his room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for three of 35 sampled residents. (Residents 5, 12, 51)Findings include: Clinical record review revealed that Resident 5 had diagnoses that included muscle contractures and cerebral infarction (stroke). Review of an occupational therapy Discharge summary dated [DATE], revealed Resident 5 was to wear bilateral (both sides) elbow splints. Review of Resident 5's care plan revealed he was on a Restorative Nursing Program (RNP) with an intervention for staff to apply bilateral elbow splints. Review of Resident 5's Minimum Data Set (MDS) assessment dated [DATE], did not indicate that Resident 5 was on a RNP for splint assistance. Clinical record review revealed that Resident 12 had diagnoses that included neurogenic bladder. A physician's order dated April 3, 2024, directed staff to care for Resident 12's bladder catheter. Review of the MDS assessment dated [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 35 sampled residents. (Resident 14)Findings include: Clinical record review revealed that Resident 14 had a diagnosis of depression. Review of the Minimum Data Set assessment dated [DATE], identified that the resident had symptoms of depression. According to the Care Area Assessment summary dated January 12, 2026, the facility identified that depression was a problem for the resident and should have been included in the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address the care area of depression. In an interview conducted on April 10, 2026, at 11:25 a.m., the Director of Nursing confirmed that there was no care plan developed with interventions to address Resident 14's depression. 28 Pa. Code 211.12(d)(5) Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards in one of six shower rooms. (B unit women's shower room)Findings include: Observations of B unit Women's Shower room on April 8, 2026, at 12:55 p.m., revealed that the entry door was not locked and was observed to be used as a common bathroom for toileting. The tub was observed to contain two disposable razors, two cans of shaving cream, one bottle of body wash and a spray bottle that was half full of a yellow/orange color liquid. In an interview on April 8, 2026, at 1:42 p.m., the Director of Nursing stated that the spray bottle contained a chemical cleaner and that there were three ambulatory residents that were cognitively impaired who could have accessed the potentially hazardous materials. 28 Pa. Code 211.12(d)(5) Nursing services.
- Potential for harm · D2026-04-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, staff interview, and review of facility policy it was determined that the facility failed to store respiratory equipment appropriately for one of three sampled residents who received oxygen therapy. (Resident 12)Findings include: Review of the facility policy entitled, Oxygen Administration, dated March 24, 2026, revealed that oxygen cannulas (a tube with two prongs where each prong is inserted into each nostril of the nose) and masks were to be changed weekly. When oxygen tubing was not in use it was to be kept in a plastic bag. Staff were to place a new bag on the side of the concentrator or portable oxygen tank weekly to hold the tubing. Clinical record review revealed that Resident 12 had diagnoses that included chronic congestive heart failure and dependence on supplemental oxygen. On December 10, 2025, the physician ordered that staff administer oxygen therapy via nasal cannula at a rate of three liters per minute at bedtime. Review of the Minimum Data Set assessment for March 17, 2026, revealed that the resident was alert and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to ensure completion of a Minimum Data Set (MDS) assessment for one of three sampled residents who were discharged from the facility. (Resident 109) Findings include: Clinical record review revealed that Resident 109 passed away in the facility on [DATE]. There was no documented evidence that an MDS assessment was completed to reflect the discharge status when the resident expired in the facility. In an interview on [DATE], at 11:00 a.m., the Administrator confirmed that the MDS had not been completed when the resident was discharged from the facility on [DATE].
- Potential for harm · Dcited before2025-03-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for four of 36 sampled residents. (Residents 5, 21, 33, and 56) Findings include: Review of the policy entitled, General Dose Preparation and Medication Administration, last reviewed November 26, 2024, revealed that staff were to obtain vital signs if necessary and document physician-indicated medication administration information. Clinical record review revealed that Resident 5 had diagnoses that included hemiplegia and hemiparesis (paralysis) and multiple sclerosis. Review of the Minimum Data Set (MDS) assessment, dated February 28, 2025, revealed Resident 5 had cognitive impairment, was at risk for developing pressure ulcers, and was dependent on staff for putting on and taking off footwear. Review of Resident 5's care plan revealed he had the potential for skin breakdown with an intervention for staff to apply bilateral pressure relieving boots. On April 4, 2024, the physician ordered for staff to apply bilateral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-11 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to four of six sampled residents. (Residents 1, 2, 3, 4) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension and chronic obstructive pulmonary disease . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident needed staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. Review of documentation in the clinical record revealed that the resident only received two showers since admission to the facility on July 4, 2024. Clinical record review revealed that Resident 2 had diagnoses that included congestive heart failure and hypertension. The MDS assessment dated [DATE], indicated the resident needed staff assistance for bathing. The resident was to receive a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · E2024-09-11 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on two of three nursing units (B and C unit) and the main dining room. Findings include: Observation on the B nursing unit on September 11, 2024, from 10:30 a.m. through 2:00 p.m. revealed the following: The wall paper was peeling and hanging off the wall in multiple areas in the common area across from the nurses' station. The floor outside the door to the janitor's closet had a large accummulation of black dirt. In rooms 101, 102, 104, 105, 106, and 107, the floors were sticky and the tiles had a dull black/brown coating of dirt accummulation. In room [ROOM NUMBER] the heating unit contained peeling paint and cobwebs near the controls. The wall to the right of the closet was heavily marred. In the shared bathroom there was a brown/black ring of dirt on floor around the bottom of the toilet, the right side toilet grab bar was loose, the wall around the soap dispenser was peeling, and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to meet each resident's needs for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension and chronic obstructive pulmonary disease. Review of the current care plan revealed that the resident had hearing loss and wore hearing aides. Review of a progress note dated August 15, 2024, revealed that Resident 1 had an appointment for the physician to clean his ears on September 6, 2024, and that the physician was to clean his ears in the facility. Review of a physician's progress note dated August 22, 2024, revealed that there was no evidence that the physician addressed or cleaned Resident 1's ears. On August 28, 2024, the physician ordered for staff to administer ear drops to both the resident's ears for seven days and then the physician would flush. There 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.
- Potential for harm · Dcited before2024-05-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based on clinical record review and staff interview, it was determined that the facility failed to provide adequate interventions and supervision to prevent elopement (leaving an area without permission or supervision) for one of eight sampled residents. (Resident CL 1) Findings include: Clinical record review revealed that Resident CL 1 had diagnoses that included chronic kidney disease. The Minimum Data Set assessment, dated September May 1, 2024, indicated that the resident was able to walk without staff assistance. Review of the current care plan revealed that Resident CL 1 was at risk to elope and an intervention was for staff to apply a wander guard (a bracelet like device that is placed on an extremity that assisted with the location of a resident who may wander) to her left wrist. A physician's order dated April 24, 2023, directed that the resident wear a wander guard and that staff check placement every shift and the function of the device daily. Review of the treatment administration records for April and May 2024, revealed that there was no documented evidence 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.
- Potential for harm · Dcited before2024-02-23 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents in two of four dining rooms. (Residents 9, 91, 205) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included Alzheimer's dementia, unspecified protein-calorie malnutrition, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated November 28, 2023, revealed that the resident had cognitive impairment. Review of Resident 9's care plan revealed the resident was to be seated upright in a chair with the assistance of one staff member while eating. On February 21, 2024, from 8:32 a.m. until 8:54 a.m., Nurse Aide (NA) 1 was observed standing while assisting Resident 9 with breakfast. Clinical record review revealed that Resident 91 had diagnoses that included diabetes mellitius. Review of the MDS assessment, dated February 20, 2024, revealed that the resident had cognitive impairment and needed 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.
- Potential for harm · Dcited before2024-02-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
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 meet each resident's needs as related to a diagnosis of post traumatic stress disorder and as identified in the comprehensive assessment for two of 31 sampled residents. (Residents 8, 21) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included post traumatic stress disorder (PTSD), depression, and Fourier's gangrene (tissue death). Review of a psychiatric consultation dated December 20, 2023, revealed Resident 8 was a combat veteran with PTSD. Review of the Resident Centered Care/All About Me Information Form dated February 3, 2024, revealed the resident had triggers from past trauma that included loud noises, fireworks, and cars backfiring. Resident 8's care plan did not include interventions to address the resident's PTSD diagnosis and related triggers to prevent re-traumatization. Clinical record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility on a consistent basis for one of 31 sampled residents. (Resident 147) Findings include: Clinical record review revealed that Resident 147 had diagnoses that included repeated falls and colon cancer. The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired and required staff assistance for activities of daily living. Review of the physical therapy Discharge summary dated [DATE], revealed that the resident required staff assistance for transfers and walking. The physical therapist recommended a restorative nursing program for Resident 147. Staff was to assist the resident to walk 150 feet daily with a walker while staff followed with a wheelchair. Review of Resident 147's current care plan revealed that he was dependent on staff assistance for transfers…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of nine sampled residents. (Residents 1, 9) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes mellitus and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and was dependent on staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. During an interview on Ocotber 28, 2023, at 9:15 a.m., the resident reported that he preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 1 stated that he would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower five of eight scheduled times in the past 30 days. Clinical record review 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.
- No harm found · B2026-04-10 · tag F0628 — patternProvide 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 staff interview, it was determined that the facility failed to notify a resident's representative of a resident's appeal rights upon transfer to the hospital or notify the Ombudsman in writing of a resident's discharge from the facility for two of seven sampled residents who were transferred to the hospital or discharged . (Residents 12 and 171) Findings include: Clinical record review revealed that Resident 12 was transferred to the hospital on December 4, 2025, after a change in condition. There was no documented evidence that the resident's responsible party was provided information regarding appeal rights. In an interview on April 10, 2026, at 9:52 a.m., the Administrator confirmed that Resident 12's representative was not provided with a transfer notice that included the required information. Clinical record review revealed that Resident 171 was discharged from the facility on March 3, 2026. There was no documented evidence that the Ombudsman was notified of the discharge. In an interview on April 10, 2026, at 12:50 p.m., Employee 3 confirmed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 4 of 5 | 2.6 | +1.4 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 125 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 125; 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 / manager | Type | Role | Since |
|---|---|---|---|
| VOLPE, BENJAMIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | since 03/01/2019 |
| WEISBERG, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 01/29/2026 |
| NICOLUZAKIS, GREGORY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 03/01/2019 |
| SHG MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2019 |
| GRAF, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| SAKALAS, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/06/2024 |
| TOBIAS, KRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/30/2024 |
| BENJAMIN N. VOLPE FAMILY DYNASTY TRUST (DATED DECEMBER 29, 2020) | Organization | ADP OF THE SNF | since 01/01/2023 |
| BNV DYNASTY LLC | Organization | ADP OF THE SNF | since 01/01/2023 |
| CITRIN COOPERMAN ADVISORS LLC | Organization | ADP OF THE SNF | since 04/01/2018 |
| DECANTED WILLIAM I. WEISBERG FAMILY DYNASTY TRUST (DATED SEPT 30, 2020 | Organization | ADP OF THE SNF | since 01/01/2023 |
| RKL LLP | Organization | ADP OF THE SNF | since 01/26/2023 |
| SABER GOVERNANCE LLC | Organization | ADP OF THE SNF | since 09/01/2019 |
| SABER HEALTHCARE GROUP LLC | Organization | ADP OF THE SNF | since 04/01/2018 |
| SHG REZ LLC | Organization | ADP OF THE SNF | since 08/13/2025 |
| TREMONT RE GROUP LLC | Organization | ADP OF THE SNF | since 05/02/2022 |
| ZIEGLER FINANCING CORPORATION | Organization | ADP OF THE SNF | since 05/02/2022 |
CMS files one row per role, so the 27 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
11 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.5M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395499. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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.