Wecare at The Green Home
37 Central Avenue, Wellsboro, PA 16901 · Non profit - Corporation · 120 certified beds · (570) 724-3131 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.4% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.6% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.8% | 10.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.0% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.9% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.3% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.8% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.9% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.2% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.9% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.5% | 9.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.72 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.65 | 1.18 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.6% 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 84 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.
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 | 55.6%CMS range 44.2–65.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 6.6–13.7 | 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 | 76.9% | 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 | 67.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 3.5% | 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 | 5.5%CMS range 3.1–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · E2024-12-13 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of resident personal fund accounting, clinical record review, and resident, family, and staff interview, it was determined that the facility failed to provide a personal fund quarterly statement for two of two residents reviewed for personal funds concerns (Residents 19 and 40). Findings include: Interview with Resident 19 on December 10, 2024, at 1:41 PM revealed that she had an idea regarding how much money she had in her personal funds account; however, she does not receive a written statement at least quarterly with her personal funds accounting. Clinical record review for Resident 19 revealed a facility Resident Personal Fund Authorization (form signed by a resident to consent to the facility management of the resident's personal fund) with an undated signature by Resident 19 that did not address the facility's obligation to provide quarterly statements that would account for all transactions occurring with the resident's personal fund. The form did not designate who would receive the accounting statement for the fund. Interview with the Nursing Home…
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 · E2024-12-13 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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 and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's mobility for one of four residents reviewed (Resident 71), maintain a resident's range of motion program for one of four residents reviewed (Resident 14), and failed to provide services to prevent a decline in a resident's range of motion for one of four resident's reviewed (Resident 11). Findings include: Observation and interview with Resident 71 on December 10, 2024, at 1:09 PM revealed she was lying on her bed. Resident 71 stated she was planning on returning home and had finished therapy, but thought she was going to do more therapy to keep her strength to return home, such as walking. Resident 71 indicated she is not to try to walk on her own and needs to use a walker and rely on staff. Resident 71 stated she lies around a lot. Resident 71 stated staff need to walk her to her bathroom. Clinical record review for Resident 71 revealed 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.
- Potential for harm · E2024-12-13 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of two residents reviewed for behaviors(Resident 12). Findings include: Clinical record review for Resident 12 revealed the following current physician orders: Ativan 0.5 milligram (mg) PO (by mouth) BID (twice daily), initially ordered September 26, 2023 Ativan 2 mg PO q HS (hour of sleep), initially ordered December 16, 2023 Ativan 1 mg PO PRN (as needed) q 4 hours (every four hours) for restlessness/anxiety for 120 days, initially ordered on October 29, 2024 Antianxiety Drug Monitoring TID (three times daily) for anxiety/insomnia Resident 12 had the potential to receive 9 mg of Ativan in a 24-hour period after October 29, 2024. Task documentation dated September 16, 2024, revealed that the hospice social worker (SW) noted that Resident 12 was in her room (verbally) rambling, won't open her eyes, talk, or touch, and won't answer questions. On October 16, 2024, Resident 12's physician…
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 · E2024-12-13 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 documentation for one of 20 residents reviewed (Resident 12). Findings include: Clinical record review for Resident 12 revealed the following current physician orders: Ativan 0.5 milligram (mg) PO (by mouth) BID (twice daily at 8:30 and 5:00 PM), initially ordered September 26, 2023 Ativan 2 mg PO q HS (hour of sleep, 8:00 PM), initially ordered September 26, 2023 Ativan 1 mg PO PRN (as needed) q 4 hours (every four hours) for restlessness/anxiety for 120 days, initially ordered on October 29, 2024 Morphine 100 mg/5 ml (20 mg/ml) 5 mg/0.25 ml PO q 2 hours for moderated pain 4-7, initially ordered on March 30, 2023 Review of Resident 12's October, November, and December 2024's MAR (medication administration record, a form to document medication administration) revealed that Employee 9, licensed practical nurse, documented the following: On October 30, 2023, at 8:28 PM Employee 9 documented that she administered Resident 12's Ativan 0.5 mg routine…
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 · E2024-12-13 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 required immunization education for four of five residents reviewed for influenza immunizations (Resident 11, 15, 46, and 59). Findings include: Review of Resident 11's immunization listing revealed that the facility administered the influenza vaccination for the 2024-2025 season on November 21, 2024. There was no documented evidence in Resident 11's clinical record to indicate that the facility provided the resident or her responsible party education regarding the risks and benefits of the vaccination. Review of Resident 15's immunization listing revealed that the facility administered the influenza vaccination for the 2024-2025 season on October 29, 2024. There was no documented evidence in Resident 15's clinical record to indicate that the facility provided the resident or her responsible party education regarding the risks and benefits of the vaccination. Review of Resident 46's immunization listing revealed that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-13 · tag F0887 — patternEducate 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 review of newly hired staff and staff interview, it was determined that the facility failed to screen, educate, and offer the COVID-19 vaccine to four of four newly hired employees (Employees 1, 2, 3, and 4). Findings include: Review of the CMS (Center for Medicare and Medicaid Services) memo (QSO-21-19-NH) published May 11, 2021, indicates that the facility is to offer current COVID-19 vaccinations to staff. Employees are to be medically screened for eligibility and educated on the risks and benefits of the vaccine. Additionally, the facility must maintain appropriate documentation to reflect that the facility provided the required COVID-19 vaccine education to staff, and whether the staff member received the vaccine. Review of the facility's new hire list revealed that Employees 1 and Employee 2, both nurse aide trainees, were hired on August 5, 2024. There was no documented evidence to indicate that the facility completed screening, offered the COVID-19 vaccine, or completed education regarding the risks and benefits if applicable. Review of the facility's new hire list…
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 · D2024-12-13 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 required notification to a resident whose payment coverage changed for one of three residents reviewed for beneficiary notices (Resident 76). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or…
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 · D2024-12-13 · 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 ensure complete and accurate Minimum Data Set (MDS) assessments for one of 20 residents reviewed (Resident 59). Findings include: Review of Resident 59's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated July 11, 2024, that indicated the facility assessed her as having a Stage 3 (full thickness skin loss that might extend into underlying tissue) pressure ulcer that was present on admission. There were no other skin issues noted on the assessment. An MDS dated [DATE], now indicated that the facility assessed her as having a Stage 3 pressure ulcer that was not present on admission. There were no other skin issues noted on the assessment. Interview with the Administrator on December 12, 2024, at 2:46 PM, confirmed that Resident 59's October 11, 2024, MDS was coded in error for her pressure ulcer status. 28 Pa. Code 211.5(f)(ix) Medical…
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 · D2024-12-13 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for two of four residents reviewed for rehabilitation concerns (Residents 24 and 40). Findings include: Interview with Resident 24 on December 11, 2024, at 9:22 AM revealed that he was provided a prosthetic leg following his left leg amputation; however, he was not using it. Resident 24 stated that staff use a mechanical lift to assist him to transfer and he was not walking at all. Resident 24 stated that the skilled therapy department did not have parallel bars (parallel bars are commonly used during physical therapy and rehabilitation, they are used as a support tool to provide a safe way to work on skills like gait training and balance) like he used in another therapy department prior to his admission to this facility, which now prevented him from taking steps with the prosthetic. Discharge summary…
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 · D2024-12-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice for one of two residents reviewed for supplemental oxygen concerns (Resident 15). Findings include: Observation of Resident 15 on December 10, 2024, at 11:41 AM revealed that she wore supplemental oxygen via a nasal canula (flexible tubing with small prongs on one end that are positioned in the nares to administer a supply of oxygen) that was attached to a wall flow meter (metered device used to control the flow of compressed medical oxygen from a wall supply) that was set at three liters per minute. Interview with Resident 15 on the date and time of the observation indicated that she believed her oxygen liter flow was to be set at three liters per minute. Clinical record review for Resident 15 revealed an active physician order for staff to administer supplemental oxygen at two liters per minute, to check oxygenation saturations (SPO2, pulse…
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 16 citations
- Potential for harm · Dcited before2024-12-13 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs related to call bell response time for two of 20 residents reviewed (Resident 38 and 71). Findings include: In an interview with Resident 71 on December 10, 2024, at 1:24 PM the resident stated she doesn't have much notice for needing to use the bathroom and relies on staff to get her there as she needs assistance to ambulate to the bathroom. Resident 71 stated it takes staff a long time to get there as she will ring the bell and wait. Resident 71 indicated she waited one hour and 5 minutes recently. A review of call bell activation logs for Resident 71 from November 27 - December 11, 2024, revealed the following (total minutes reflect time in seconds from reports): December 3, 2024, call bell activated at 1:03 PM, response at 1:20 PM, 16 minutes. December 6, 2024, call bell activated at 9:24 PM, response at 9:46 PM, 21 minutes. December 8, 2024, call bell activated at 10:50 AM, response at 11:05 AM, 15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, it was determined that the facility failed to ensure locked storage of medication during medication administration pass for one of six residents observed for medication administration (Resident 7). Findings include: Observation of a medication administration pass on December 11, 2024, at 8:38 AM revealed Employee 10 (licensed practical nurse) administered medications to Resident 7. Resident 7 refused to take her Metoprolol medication (medication used to lower blood pressure) because she feared that it would lower her blood pressure excessively. Employee 10 removed the Metoprolol medication from the cup that contained the remainder of Resident 7's scheduled medications. Observation of Employee 10 on December 11, 2024, at 8:42 AM revealed that she put the tab of Resident 7's Metoprolol medication in an open plastic cup on top of the medication cart and stated that she would dispose of it at the nurses' station when she was completed with her morning medication administration pass. Employee 10 then began preparing medications for the next…
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 · D2024-12-13 · tag F0791 — failed to provide routine dental services — isolatedProvide 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 ensure routine dental services for one of two residents reviewed for dental concerns (Resident 40). Findings include: Interview with Resident 40 on December 10, 2024, at 12:16 PM revealed that she had natural teeth; however, had not received services from dental professionals in the past year (e.g., for routine prophylactic cleaning of her teeth). The surveyor requested any evidence that Resident 40 received routine dental services in the past year during an interview with the Nursing Home Administrator and the Director of Nursing on December 11, 2024, at 1:45 PM. Clinical record review for Resident 40 revealed a summary report from the facility's contracted dental provider that indicated that Resident 40 last received services from the professional dentist on October 4, 2022 (more than two years ago). The summary report indicated that Resident 40 received professional dental hygienist services on April 26, 2023 (approximately one and one-half years ago). Interview 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 · F2024-01-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, it was determined that the facility failed to maintain linens in a sanitary manner in the facility's main linen supply storage area. Findings include: In an interview with Employee 6, Assistant Director of Nursing, on January 12, 2024, at 11:30 AM, Employee 6 indicated the facility does not complete any laundering of linens or resident items in the facility and items were sent out of the facility to be laundered. In a concurrent observation of the area, clean linens and laundry are returned to the facility that Employee 6 revealed to be an area through a door in the back service hallway of the facility. Upon entering the door, a storage area behind a metal cage was observed on the left, which contained mattresses and multiple other items. Just past the cage area on the left was a man observed working at a table, multiple tools and equipment were observed in the area, which Employee 6 confirmed was the maintenance shop area. On the left side of the other room after the maintenance shop area, not separated by any walls or rooms, only shelving…
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 · E2024-01-12 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing and dressing assistance for a resident dependent on staff assistance for one of two residents sampled for activities of daily living (Resident 31). Findings include: Observation and interview with Resident 31 on January 9, 2024, at 1:17 PM revealed Resident 31 was out of bed in her personal chair, still in her nightgown. Her hair appeared disheveled. Interview with Resident 31 at this time stated she needs staff assistance to get dressed. Resident 31 stated she prefers to get dressed in comfortable clothes. She stated she does not have a specific shower day, she indicated she lets the staff know when she wants a shower if staff are available. Observation of Resident 31 on January 10, 2024, at 11:40 AM revealed Resident 31 was out of bed, but she was still in her nightgown. Clinical record review revealed the facility admitted Resident 31 on May 23, 2023. A review of Resident 31's most recent MDS (Minimum Data Set, an assessment completed 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.
- Potential for harm · E2024-01-12 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure 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 the review of facility documentation and staff interviews, 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 resident tracheostomy and catheter care. Findings include: A review of the facility documentation revealed that the facility had nine residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine) and one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea). A request for nursing staff competencies for tracheostomy and catheter care revealed the facility was unable to provide any. An interview with Employee 6 (acting director of nursing) on January 12, 2024, at 12:27 PM confirmed the facility could provide no documentation that ensured nurses have specific competencies and skill sets to care for the residents' needs listed above. 28 Pa Code 201.20(a) Staff development 28…
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 · E2024-01-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, it was determined that the facility failed to store food service equipment in a sanitary manner in the facility's main kitchen. Findings include: An observation of the main kitchen on January 9, 2024, at 12:36 PM revealed a large open utensil storage rack was located at the end of a production table in the food preparation area. The tall rack, which extended higher than the production table contained multiple spoons, whisks, spatulas, and ladles, hanging from the rack. The food contact surfaces of the utensils were exposed to dust/debris as well as splatter/splash from items being prepared on the food preparation table. Concurrent interview with Employee 5, dietary supervisor, indicated the utensils were considered clean and available for dietary employees to use in food service and production and it was not expected of the staff to wash/sanitize the utensils before use. An observation in the main kitchen on January 11, 2024, at 11:00 AM revealed dietary staff obtaining utensils from the above utensil rack and placing them in front of pans…
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 · D2024-01-12 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 respect a resident's right to privacy for two of 19 residents reviewed (Residents 8 and 65). Findings include: Clinical record review for Resident 8 revealed nursing documentation dated January 1, 2024, noting Resident 8 was found on the floor and the nurse noted the baby monitor was in use. Clinical record review for Resident 65 revealed nursing documentation dated December 22, 2023, noting Resident 65 was found on the floor and staff heard the chair alarm going off through the baby monitor at the nurses' station. A review of the facility investigation into Resident 65's fall revealed she is to have a voice monitor when in closed-door isolation. Interview with Employee 1 (assistant nursing home administrator) on January 12, 2024, at 1:30 PM confirmed the facility was utilizing baby monitors (audio amplifiers) in resident rooms. She stated the facility used the baby monitors to amplify the sound of resident alarms. There was no evidence in Resident 8 or 65's clinical records that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, and resident and staff interview, it was determined that the facility failed to thoroughly investigate and report misappropriation of resident property for one of 19 residents reviewed (Residents 36). Findings include: The facility policy entitled, Abuse, Neglect, Exploitation General Policy, effective June 2022, and last revised in January 2024, revealed that the facility goal is to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves but is not limited to identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and /or misappropriation of resident property is more likely to occur. The facility is responsible to investigate and report cases of possible abuse, neglect including involuntary seclusion, exploitation, and misappropriation of property to external agencies in accordance with the regulation. All facility employees, family members, and volunteers are educated that all alleged or suspected…
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 · D2024-01-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 interview, it was determined that the facility failed to medically justify and evaluate the clinical necessity for a urinary catheter for one of three residents reviewed for catheter use (Resident 65) and implement appropriate services for one of three residents reviewed for catheter use (Resident 26). Findings included: Clinical record review revealed the facility admitted Resident 65 on August 21, 2023, without an indwelling urinary catheter (insertion of a tube into the bladder to remove urine) . Resident 65 was admitted to the hospital from [DATE] to 15, 2023, and a Foley catheter was placed in Resident 65 due to terminal illness. An observation of Resident 65 on January 9, 2024, at 10:55 AM revealed a catheter remained in place. A review of Resident 65's clinical record revealed a Physician Notification/Order Request Form, dated November 22, 2023, indicating the nurse requested the physician add a diagnosis of obstructive uropathy. Further review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review 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 eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 42). Findings include: Clinical record review for Resident 42 revealed a current diagnosis of Chronic Post Traumatic Stress disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). During an interview with Resident 42 on January 12, 2024, at 9:13 AM upon discussion of her PTSD diagnosis, the resident stated being asked the same questions over and over and having staff she doesn't know triggers her stress. Resident 42 did not elaborate on any other details of her trauma. Clinical record review for Resident 42 revealed an active plan of care for the resident for PTSD, which included interventions of psychiatry/psychology as ordered, encourage to maintain relationships with family and friends,…
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 · D2024-01-12 · tag F0744 — failed to care for residents with dementia — isolatedProvide 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 two of two residents reviewed (Residents 30 and 63). Findings include: Clinical record review for Resident 30 revealed the facility admitted her on July 17, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 30's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated July 18, 2023, indicated that the facility assessed Resident 30 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 30's care plan revealed a problem for impaired cognitive/communication skills for daily decision making due to a diagnosis of dementia. 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 · E2023-01-20 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of two residents reviewed (Resident 51). Findings include: The facility policy entitled, Pain Management, last reviewed without changes in October 2022, revealed that staff will follow a modified pain scale of 1-3 for mild pain, 4-7 for moderate pain, and 8-10 for severe pain to describe and evaluate pain. Clinical record review for Resident 51 revealed physician's orders for the following pain medications: Ordered on June 28, 2021, Acetaminophen Tablet 325 milligram (mg) two tablet by mouth (PO) every 4 hours as needed (PRN) for mild pain, not to exceed 3000 mg per 24-hour period. Ordered on October 6, 2022, Oxycodone 5 mg/Acetaminophen 325 mg one tablet PO every 8 hours PRN moderate to severe pain. Review of Resident 51's November and December 2022 and January 2023 MAR (medication administration record, a form to document medication administration) revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-20 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of select facility policies, employee personnel records, clinical record review, and staff interview, it was determined that the facility failed to implement an abuse prohibition policy pertaining to screening for three of five newly hired employees reviewed (Employees 2, 3, and 4), and investigate the potential for neglect for one of one resident reviewed (Resident 65). Findings include: The current facility policy entitled, Abuse: Prevention, Investigation & Reporting, last revised March 2020, revealed it is the facility guidelines that a resident/situation will be assessed for signs of physical, sexual, mental, or verbal abuse, involuntary seclusion, and neglect. The policy also revealed the facility will screen potential employees, that criminal background checks and employment verifications according to human resources policy are requested for each new employee. Review of the facility policy entitled Employment Verification/Pre-Placement Evaluations/References, dated July 28, 2022, revealed the facility has approved outside background check and employment…
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 · D2023-01-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of select facility policies, clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding elopement risks for two of 18 residents reviewed (Residents 4 and 64). Findings Include: Review of the policy entitled Wandering/Elopement, last revised September 2022, indicates that the purpose is to identify residents who are at risk for elopement and implement interventions to prevent this. If they are found to be at risk, this will be communicated in the communication book and recorded in their support plan. Review of Resident 4's clinical record revealed nursing documentation dated November 12, 2022, at 1:31 PM, that indicated Resident 4 was missing. Staff searched the facility and outdoors. Staff also was searched for the resident in nearby locations. She was found by Wellsboro Nutrition (2 blocks from the facility) and was accompanied back to the facility. Once returned, Resident 4 stated she should have had warmer clothes. The facility completed a Wander Risk…
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 before2023-01-20 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of call bell response logs, clinical record review, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs for one of 18 residents reviewed (Resident 40). Findings include: Review of Resident 40's Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated November 29, 2022, indicated the facility assessed her as being cognitively intact and needing the extensive assistance of two staff members for toileting. During an interview with Resident 40 on January 17, 2023, at 12:40 PM she indicated that just last evening she had to wait almost an hour for nursing staff to answer her call bell and help her get off the toilet. Resident 40 also indicated that staff will come and answer her call bell but turn it off without helping her and say that they will return but end up never coming back. Review of the facility's call bell logs dated January 16, 2023, revealed that Resident 40's call bell was activated from 6:57 PM until 7:53 PM, for 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.
“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 UPMC SENIOR COMMUNITIES — 6 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 | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 3.7 | -2.7 vs chain |
| Quality measures | 5 of 5 | 3.5 | +1.5 vs chain |
The other 5 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| UPMC SUSQUEHANNA | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2016 |
| UPMC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 10/01/2016 |
| EVENS, JAMIE | Individual | CORPORATE DIRECTOR | — | since 08/01/2024 |
| POIRIER, GLENN | Individual | CORPORATE DIRECTOR | — | since 08/01/2024 |
| PARSELL, MARLENE | Individual | CORPORATE OFFICER | — | since 01/01/2025 |
| REYNOLDS, RON | Individual | CORPORATE OFFICER | — | since 12/20/2021 |
| WOOLCOCK, BOBBIE | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/02/2025 |
| YOST, ROGER | Individual | CORPORATE OFFICER | — | since 08/01/2024 |
| BURNS, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/08/2025 |
| JAUSSI, LARA | Individual | ADP OF THE SNF | — | since 04/03/2020 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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
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 395318. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-13, 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.