Park Lane Post Acute LLC
1619 East Boot Road East Goshen, West Chester, PA 19380 · For profit - Corporation · 68 certified beds · (484) 653-4400 Medicare only — no Medicaid
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 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 | 0.0% | 16.8% | 15.4% | check this* — see note marked star below the table |
| Long-stay residents who lose too much weight | 0.0% | 6.2% | 5.4% | check this* — see note marked star below the table |
| 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 | 14.0% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 19.4% | 20.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 90.5% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 42.1% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.4% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 41.9% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.0% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.2% | 9.5% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. 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.
61.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 505 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.2% 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 298 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 0.76 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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 | 61.0%CMS range 56.7–64.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 8.4–13.0 | 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 | 78.2% | 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 | 72.5% | 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 | 73.5% | 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 | 99.5% | 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 | 91.2% | 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 | 98.5% | 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 | 1.3% | 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 | 2.3% | 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 | 6.8%CMS range 4.7–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 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 68 beds and averages 63.6 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.26 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 3.72 hrs/resident/day on weekends vs 3.95 on weekdays — 6% thinner on weekends. RN hours go from 1.41 to 0.89 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-07 · 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 staff and resident interview, observation, and clinical record review, it was determined that the facility failed to monitor a resident's skin after the application of an elastic wrap for one out of six residents reviewed (Resident 37).Findings include: A review of Resident 37's admission Minimum Data Set (MDS - a mandatory assessment of a resident's condition and care needs) dated April 20, 2026, revealed Resident 37 was moderately cognitively impaired and relied on staff for substantial assistance with personal care. Resident 37's diagnoses included pneumonia (a lung infection), acute respiratory failure (a condition where the lungs cannot provide enough oxygen to the blood), pulmonary hypertension (a type of high blood pressure affecting the blood vessels in the lungs and the right side of the heart), and cardiomyopathy (enlargement of the heart muscle). Resident 37 was receiving diuretic medication (removes excess fluid from the body), opioid medication (a narcotic pain medication), antiplatelet medication (medication to prevent blood clots), anticonvulsant medication…
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 before2026-05-07 · 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 observation, review of facility policy, and clinical record review, it was determined that the facility failed to ensure physician orders for oxygen for one out of six residents reviewed (Resident 25).Findings include:Review of facility policy titled Oxygen Administration, undated, revealed the following: Oxygen is administered under orders of a provider, except in the case of an emergency where the resident [is] exhibiting signs and symptoms of respiratory distress.Review of Resident 25's admission Minimum Data Set (MDS - a mandatory assessment of a resident's condition and care needs) dated March 11, 2026 revealed Resident 25 was moderately cognitively impaired and totally dependent on staff to complete care needs. Resident 25's diagnoses included lung cancer and chronic respiratory failure (a condition where the lungs cannot deliver oxygen to the blood). Resident 25 was receiving antianxiety medication, hypnotic medication (medication for sleep), anticoagulant medication (medication to prevent blood clots), antibiotic medication (medication to treat infections), opioid…
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 before2026-05-07 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that medications ordered by physicians were available for two of 19 residents reviewed (Residents 4 and 5).Findings Include: A review of Resident 4's readmission notes dated April 8, 2026, at 10:28 p.m., revealed the resident was readmitted with a left hip fracture, post ORIF (Open Reduction and Internal Fixation- A two-part surgical procedure used to treat severe, displaced bone fractures by realigning the bone and securing it with hardware) to the left hip. A review of Resident 4's physician's order dated April 8, 2026, revealed Heparin Sodium (anticoagulant) injection solution one ml (milliliter) subcutaneously (medication injected into the fatty tissue layer between the skin and muscle) every eight hours for DVT (Deep Vein Thrombosis- blood clot in the deep vein) prevention. A review of Resident 4's April 2026 Medication Administration Record (MAR) revealed Heparin was not administered on the following dates/times: April 27, 2026, at 6:00 a.m., 2:00 p.m., and 10:00…
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 before2026-05-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's policy, clinical records review, observations, and staff interviews, it was determined that the facility failed to practice infection control prevention and management for one of two residents reviewed (Resident 71).Findings:A review of the facility's policy titled Transmission-Based (Isolation) Precautions, revised on March 16, 2026, revealed that facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The same policy revealed, healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those…
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 before2026-01-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical and pharmacy records and staff interviews, it was determined that the facility failed to ensure medications were made available for one of the two residents reviewed (Resident CL1).Findings include: Clinical records review revealed Resident CL1 was admitted to the facility on [DATE], with a diagnosis of T11-T12 compression fracture. A review of the Physician's order (POS) dated November 26, 2025, revealed Lyrica (A medication used to treat nerve pain and seizures) 25 mg one capsule by mouth three times daily. The medication was scheduled at 9:00 a.m., 1:00 p.m., and 9:00 p.m. A review of the November 2025 Medication Administration Record (MAR) revealed that Resident CL1 was not administered Lyrica on November 27, 2025, at 9:00 a.m., 1:00 p.m., and 9:00 p.m. A review of the nursing progress notes dated November 27, 2025, at 10:39 a.m., revealed Lyrica medication not yet in from pharmacy. A review of the nursing progress notes dated November 27, 2025, at 12:12 p.m., revealed Lyrica…
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 · E2025-05-16 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders and adequately monitor significant weight changes for three of eight residents reviewed for nutrition (Residents 18, 36 and 37). Findings include: Review of facility policy, Weight and Weight Change Management, last revised date unknown, revealed: Resident weights will be obtained to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Each resident will be weighed monthly or more frequently as deemed necessary by physician orders, Dietician, or IDT (interdisciplinary team) recommendation. Clinical records review revealed Resident 18 was admitted to the facility on [DATE], with diagnosis of Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Chronic Kidney Disease (CKD-Gradual loss of kidney…
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 · D2025-05-16 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to monitor behaviors and potential side effects for residents receiving anti-psychotic medications (psychiatric drugs used to treat symptoms of psychosis, like hallucinations and delusions) for two of five residents reviewed (Residents 18 and 25). Findings include: A review of the facility's policy titled Psychotropic Medications, with an effectivity date of January 14, 2025, revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. The medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Further review of the same policy revealed that residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS- A test used to assess and monitor involuntary movements) test performed per facility policy. A review of Resident 18's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-16 · 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 a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to thoroughly investigate allegations of staff being rough to the resident while providing care for one of the 19 residents reviewed (Resident 62). Findings include: A review of the facility's policy titled Abuse, Neglect and Exploitation, implemented on March 17, 2025, revealed that an investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occurs. Written procedures for investigations include the following: Identifying staff responsible for investigation; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might know about the allegation; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and the cause; and Providing complete and thorough documentation of the investigation. A review of Resident 62's diagnosis list includes Spinal Stenosis…
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 before2025-05-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure skin impairment identified from admission was thoroughly assessed and wound care recommendations from the wound physician were followed for one of four residents reviewed (Resident 59). Findings include: A review of the facility's policy titled Pressure Injury Prevention and Management, implemented on January 14, 2025, revealed that the facility should establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Clinical records review revealed Resident 59 was admitted to the facility on [DATE], with a diagnosis of progressive supranuclear ophthalmoplegia (A late-onset neurodegenerative disease…
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 · D2025-05-16 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of nutrition for one of two residents reviewed (Resident 317). Findings include: Review of Resident 317's Medical Diagnosis revealed, unspecified protein-calorie malnutrition and chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels or high carbon dioxide levels). Clinical record review that patient was admitted to facility on May 8, 2025 with a tracheostomy (a surgical procedure where an opening (stoma) is created in the neck to access the trachea (windpipe), allowing for easier breathing) and PEG tube (a thin, flexible tube inserted directly into the stomach through the abdominal wall). Review of Resident 317's physicians order revealed an order dated May 8, 2025 for Enteral Feed Order one time a day Continuous Tube Feeding: Product: Nutren 1.5 At 60 ML/ Hour via PEG tube x 20hours/day Total Volume: 1200 mL (milliliter) Up at 4 pm…
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 15 citations
- Potential for harm · Dcited before2025-05-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records facility policy review and staff interviews, it was determined that the facility failed to follow physician orders for oxygen for one of one residents reviewed. (Resident 317) Findings include: Review of Facility policy titled Tracheostomy Care, undated, revealed the following: The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. And tracheostomy care will be provided according to the physicians orders, comprehensive assessment and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. Review of resident 317's Diagnosis list revealed, chronic respiratory failure with hypoxia (Respiratory failure is a condition where there's not enough oxygen or too much carbon dioxide in your body. It can happen all at once (acute) or come on over time (chronic). Review of Resident 317's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical records review and staff interview, it was determined that the facility failed to ensure medications were made available for one of the 19 residents reviewed (Resident 18). Findings include: A review of Resident 18's diagnosis list includes bipolar disorder (A disorder associated with mood swings ranging from depressive lows to manic highs), Major Depression, and Sleep Apnea (A potentially serious disorder in which breathing repeatedly stops and starts). A review of Resident 18's physician's order dated April 23, 2025, revealed an order of Armodafinil 250 mg (A medication that treats sleepiness from narcolepsy, sleep apnea, or night shift work) one tablet one time a day for sleep disorder. A review of the April 2025, Medication Administration Record revealed Armodafinil medication was not administered to Resident 18 on April 24, 25, 26, 27, and 28, 2025. A review of the nursing progress notes dated April 25, 2025, at 8:52 a.m., revealed Armodafinil medication was still on order from the pharmacy, the physician was notified. A review of the nursing progress notes…
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 · D2025-05-16 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and staff interviews, it was determined that the facility failed to store food in a sanitary manner. Findings include: Observations in the walk-in freezer on March 15, 2025, revealed that there was a large accumulation of ice on the fans and ceiling extending down to the food boxes on the top shelf. Interview with the Dietary Director on March 15, 2025, at 11:40am confirmed the ice buildup and stated, it is cleaned up after lunch. Observation in the walk freezer on March 16, 2025, at 9:08am revealed accumulation of ice on the fan still present ice on the fans and on ceiling. Interview with the Nursing Home Administrator on March 16, 2025, at 1:15 confirmed the above statement. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services
- Potential for harm · F2024-04-19 · tag F0642 — widespreadEnsure a qualified health professional conducts resident assessments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and Minimum Data Set (MDS-mandated assessments of a resident's abilities and care needs) assessments, and a staff interview, it was determined that the facility failed to timely certify the completion of the MDS assessments for nine of nine sampled residents (Residents 6, 40, 42, 50, 57, 65, 76, 77, and Resident 99). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated [DATE], indicated that the MDS Completion Date must be no later than 14 days after the Assessment Reference Date. Review of Resident 6's progress note of [DATE], revealed that resident was discharged to home. Review of Resident 6's clinical record revealed that a discharge MDS assessment dated [DATE], was not completed and was listed as in progress. Review of progress note of [DATE], revealed that orders were received to discharge the resident home. Further review of the clinical…
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 · Fcited before2024-04-19 · 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 upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for three of three reviewed (Residents 50, 212, and 213). Findings include: Review of facility policy and procedure titled Enhanced Barrier Precautions, revised March 26, 2024, revealed Enhanced Barrier Precautions (EBP) expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multidrug resistant organism (MDROs) to staff hands and clothing. Further review of facility policy and procedure revealed EBP are indicated for residents with any of the following and should be used: infection or colonization with a CDC-targeted MDRO when Contact Precautions do otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO;…
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 · E2024-04-19 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual, clinical record review and staff interview, it was determined that the facility failed to ensure that the comprehensive Minimum Data Set assessments were completed in the required time frame for five of 12 residents reviewed (Residents 27, 166, 212, 214, 262) Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a comprehensive admission MDS assessment was to be completed no later than 14 days following admission and an annual assessment not less than once every 12 months. Review of Resident 27's clinical record revealed that an admission MDS assessment with an ARD (assessment reference date - last day of the assessment's look-back period) of April 17, 2023. The MDS is not completed and is listed as in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-19 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for four of 12 residents reviewed (Residentsv 5, 22, 50, and 211 ). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated October 2019, indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date. Review of Resident 5's clinical record revealed a quarterly assessment with an ARD (assessment reference date - last day of the assessment's look back period) of March 15, 2024. The assessment was not completed and is listed as in progress. Review of Resident 22's clinical record revealed a quarterly assessment with an ARD of March 6, 2024. The assessment was not completed. Review of Resident 50's clinical record 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 · D2024-04-19 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and interview with staff, it was determined that the facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred or discharged for three of three residents reviewed (Residents 50, 64, and 76). Findings include: Review of Resident 50's clinical record revealed a nursing progress note dated December 15, 2023, revealed that the resident had a new order to be sent to the hospital to be evaluated due to bilateral lower extremity pain. Further review of Resident 50's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident 50's transfers from the facility to the hospital. Review of Resident 64's nursing progress notes dated March 17, 2024, at 10:14 p.m., revealed resident was sent back to the hospital for further treatment (right knee infection). Review of Resident 64's clinical record failed to reveal the State Ombudsman's office was notified of Resident 64's transfers from the facility to the hospital. Review of Resident 76's clinical progress notes dated…
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 · D2024-04-19 · 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 MDS assessments accurately reflected the resident's status for two of 12 residents reviewed (Residents 50 and 212). Findings include: Review of Resident 50's hospital readmission skin assessment dated [DATE], indicated resident had a left medial ankle venous stasis ulcer (slow healing sores on the legs caused by poor circulation). Review of the admission MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated December 25, 2023, section M1030 Number of Venous and Arterial Ulcers indicated that Resident 50 did not have any venous or arterial ulcers. Interview with the Director of Nursing, on April 19, 2024, at 1:30 p.m. confirmed that Resident 50 was admitted with the venous ulcer and the the assessment did not accurately reflect the resident's status. Review of Resident 212's clinical progress note dated March 29, 2024 revealed Patient was admitted to Room [number] via stretcher…
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 · D2024-04-19 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 upon review of clinical records, it was determined the facility failed to ensure baseline care plans were completed upon admission for three of 18 residents reviewed (Residents 93, 212 and 213). Findings include: Clinical records review revealed Resident 93 was admitted to the facility on [DATE], with a PICC (Peripherally Inserted Central Catheter) line to the right upper arm. Review of Resident 93's physician order dated April 12, 2024, revealed an order for Micafungin Sodium (Anti-fungal medication) Intravenous Solution 100mg one time a day for post abdominal surgery for ten days. Review of Resident 93's current care plan revealed that a care plan for the Resident's presence of PICC line and IV Anti-Fungal medication administration was not developed. Interview with the Director of Nursing on April 19, 2024, at 1:00 p.m., confirmed a baseline care plan for the presence of PICC line and IV anti-fungal medication was not developed for Resident 93. Review of Resident 212's clinical record revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-19 · 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 review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 12 residents reviewed (Resident 50). Findings include: Review of Resident 50's physician's orders included an order dated December 22, 2023, for Heparin Sodium (anticoagulant - blood thinner) Injection 5000 units subcutaneously (under the skin) every 12 hours. Review of Resident 50's current active care plan revealed no care plan or interventions for anticoagulant medication. Review of Resident 50's wound assessment dated [DATE], revealed resident had arterial wounds (wounds caused by poor circulation) of the right and left ankles, the left first MTP (metatarsophalangeal - joints connecting bones of the foot to the toes), right medial foot, right lateral ankle, and left and right heels. Resident 50 also had a venous ulcer (slow healing sore caused by weak blood circulation) of the left calf and pressure ulcers (areas of damaged skin and tissue caused by sustained…
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 before2024-04-19 · 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 a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to follow the physician's weight monitoring order for two of the 12 residents reviewed (Resident 64 and 263). Findings include: A review of the facility's policy titled Weights Policy, dated August 1, 2023, revealed residents will be weighed as directed by the physician, federal/state regulations, or standards of practice. Clinical records review revealed Resident 64 was re-admitted to the facility on [DATE], with the following diagnoses: Lymphedema (A swelling that generally occurs in an arm or leg caused by lymphatic system blockage), and right knee infection. A review of Resident 64's physician's order sheet (POS) dated March 26, 2024, revealed an order for daily weights times three every day shift for monitoring for three days. Review of Resident 64's March 2024, Treatment Administration Record (TAR) revealed resident's weight was not done on March 27, and 28, 2024. 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 · Dcited before2024-04-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to follow a physician's order and the wound specialist recommendation for one of four residents reviewed (Resident 262). Findings include: Review of Resident 262's clinical record revealed Resident 262 was admitted to the facility with a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the sacrum. Review of Resident 262's physician's order dated January 19, 2024, revealed a wound treatment to clean the sacral wound with an acetic wash, pat dry, and apply Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) with calcium alginate and cover with foam dressing. Review of Resident 262's wound consult dated March 12, 2024, revealed improving the stage four wound to the sacrum, treatment recommendation was to cleanse the wound with saline solution (changed from Acetic wash), apply Medihoney with calcium alginate, and cover it with foam dressing. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-19 · 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 a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to provide treatment and services to maintain/restore bladder continence of one of the 12 residents reviewed (Resident 64). Findings include: Review of the facility's policy titled Bowel and Bladder - Continence, dated October 15, 2018, revealed that the facility has a standard in place for all residents related to bowel and bladder management and continence care. The procedure includes the following: Begin with a two-hour daytime voiding schedule; Approach the resident at the scheduled time; Wait five seconds to allow an opportunity to self-initiate toileting; Prompt the resident with verbal cueing if needed; Assist the resident with the toileting needs; Adjust the schedule up or down as needed, do not exceed four-hour intervals; and consult with therapy and nursing regarding changes/concerns. Review of Resident 64's admission Minimum Data Set (MDS- A standardized assessment tool…
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 before2024-04-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record reviews and staff interview, it was determined that the facility failed to ensure medications were made available for one of the 12 residents reviewed (Resident 93). Findings include: Review of Resident 93's diagnosis list includes hypertension (Elevated blood pressure), and Atherosclerotic Heart Disease (ASHD-heart condition in which an accumulation of fatty substances results in the narrowing of arteries and causing restriction in the flowing of blood). Review of Resident 93's physician order dated April 12, 2024, revealed an order for Verapamil HCL ER 240 mg(miligram) given one tablet daily by mouth at bedtime for hypertension. Review of Resident 93's April 2024, Medication Administration Record revealed Verapamil medication was not administered to the resident until April 16, 2024, four days after it was ordered. Review of Resident 93's nursing progress notes dated April 12, 2024, at 9:46 p.m., revealed medication on route from the pharmacy. Review of Resident 93's nursing progress notes dated April 14, 2024, at 8:07 p.m., revealed waiting for pharmacy…
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 PRESTIGE HEALTHCARE ADMINISTRATIVE SERVICES — 15 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 | 3.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 3 of 5 | 2.9 | +0.1 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 14 homes this chain runs (chain average 3.2★, 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 |
|---|---|---|---|---|
| PLPA HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/17/2024 |
| AYSAN TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/17/2024 |
| COPPER DE TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/17/2024 |
| GOLD DE TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/17/2024 |
| PA & DE NOBLE PARENTCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/17/2024 |
| SILVER DE TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/17/2024 |
| STAR PA I HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/17/2024 |
| STAR PA I TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/17/2024 |
| ELLENBOGEN, MOSS | Individual | CORPORATE DIRECTOR | — | since 06/17/2024 |
| HUYETTE, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/14/2025 |
| HYKES, JONATHON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/03/2025 |
CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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.
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Pennsylvania Medicaid page for homes that do.
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 396082. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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.