West Reading Skilled Nursing And Rehabilitation Ce
425 Buttonwood Street, West Reading, PA 19611 · For profit - Corporation · 176 certified beds · (610) 373-5166 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 3 to 2 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 | 26.7% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.1% | 6.2% | 5.4% | typical |
| 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 | 2.4% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 45.6% | 10.8% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 27.0% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.8% | 20.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 74.5% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.5% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.5% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.5% | 17.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 41.9% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.2% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.6% | 9.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.05 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.90 | 1.18 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.5% 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 43 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 46.4%CMS range 30.7–58.2 | 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 | 10.6%CMS range 6.9–15.3 | 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 | 39.5% | 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 | 37.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.2% | 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 | 64.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.3% | 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 | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 4.0–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 176 beds and averages 152.4 residents a day — about 87% occupied, or roughly 24 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 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.80 hrs/resident/day on weekends vs 3.24 on weekdays — 13% thinner on weekends. RN hours go from 0.45 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above 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.
31 citations, most serious first. The 10 most serious are shown; the remaining 21 are one tap away and print in full.
- Potential for harm · E2026-05-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for five of 11 sampled residents. (Residents 2, 5, 8, 9, 11)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment, and required assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Tuesdays and Fridays. In an interview on May 2, 2026, at 10:03 a.m., Resident 2 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 2 received, was offered, or refused a shower on April 3, 7, or 28, 2026.…
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 before2026-01-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one of 31 sampled residents. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included muscle wasting, dysphagia (difficulty in swallowing), protein-calorie malnutrition, and history of a traumatic brain injury. Review of the Minimum Data Set (MDS) assessment, dated December 19, 2025, revealed that the resident had significant cognitive impairment and required staff assistance with eating. Review of Resident 3's care plan revealed that staff was to assist the resident with meals as needed, encourage the resident to take small bites, provide verbal cues to take frequent drinks, and check for food in the mouth after swallowing. On January 28, 2026, from 12:25 p.m. through 12:40 p.m., licensed practical nurse (LPN) 1 was observed standing while assisting Resident 3 with lunch. In an interview on January 29, 2026, at 11:00 a.m., the Director 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 before2026-01-29 · 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 that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of three of 31 sampled residents. (Residents 1, 10, 13)Findings include: Clinical record review revealed that Resident 1 received oxygen therapy starting on September 25, 2025. The MDS assessment dated [DATE], incorrectly indicated in Section O (Special treatments, Procedures, Programs) that the resident was not receiving oxygen therapy during the previous seven days. In an interview on January 29, 2026, at 10:50 a.m., the Director of Nursing confirmed that Resident 1's MDS assessment was inaccurate. Clinical record review revealed that Resident 10 had diagnoses that included hepatic (liver) failure and asthma. Review of Resident 10's MDS dated [DATE], indicated that Resident 10 received an anticoagulant medication. Review of Resident 10's clinical record revealed no physician's orders for an anticoagulant…
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 before2026-01-29 · 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 clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 31 sampled residents. (Residents 1 and 30)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included hypertension (high blood pressure) and renal dialysis. A physician's order dated December 12, 2025, directed staff to administer a blood pressure medication (midodrine) three times a day on Tuesday, Thursday, Saturday, and Sunday and two times a day on Monday, Wednesday, and Friday. The physician ordered that staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 130 millimeters of mercury (mm/Hg). Review of Resident 1's Medication Administration Records (MARs) for December 2025 and January 2026, revealed that staff administered midodrine three times in December and four times in January when Resident 1's SBP was greater than 130mm/Hg. Clinical record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-29 · 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
Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 31 sampled residents. (Resident 113)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, (EBP) last reviewed November 14, 2025, revealed that enhanced barrier precautions were to be used with any resident with an indwelling medical device when contact is expected. Precautions included the use of protective gowns during the high risk activities and staff were to be trained on what was considered high risk activity. Clinical record review revealed that Resident 113 had diagnoses that included a stroke and dysphagia (difficulty in swallowing), and had a gastrostomy tube (a tube to deliver nutrition, fluids, or medication directly into the stomach) in place. Review of the Minimum Data Set assessment, dated November 3, 2025, revealed that the resident had significant cognitive impairment and had a feeding tube. Review of Resident 113's care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-29 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — the official record, unedited, may be distressing
Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain a fully functioning resident call bell system for one of 31 sampled residents. (Resident 30).Findings include:Review of the facility policy NSG Call Lights, dated November 15, 2025, revealed the statement, Patients will have a call light or alternative communication device at each patient's bedside, toilet, and bathing room to allow patients to call for assistance when unattended. Observation on January 27, 2026, at 11:27 a.m., revealed the call light failed to light and the signal failed to sound at the nurse's station when the button on the cord at Resident 30's bed was pressed. During an interview at 11:45 a.m., Nurse Aide 1 (NA 1) confirmed the cord was damaged and required replacement.During an interview on January 28, 2026, at 1:30 p.m., the Administrator confirmed that the facility failed to maintain a fully functioning resident call bell system in one room.28 PA Code 201.14(a) Responsibility of licensee.28 Pa Code 205.28 (c)(1) Nurses' station.
- Potential for harm · Ecited before2025-02-18 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide care and services in a manner that maintained each resident's dignity and preferences to promote quality of care for four of seven sampled residents. (Residents 1, 2, 3, 4) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included major depressive disorder and hyperlipidemia. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was not cognitively impaired. A review of the care plan revealed that the resident had an activities of daily living, (ADL), care deficit related to cognitive deficits and the intervention was for staff to assist with hygiene and grooming. Review of the shower/bathing documentation revealed that the preferred shower schedule was on Mondays and Thursdays during the day shift. Review of the shower documentation between January 2, 2025, through February 17, 2025, revealed that there were twelve…
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 before2024-12-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of three nursing units. (Nursing unit 2) Findings include: Review of the facility policy entitled, Food Handling, dated November 15, 2024, revealed that staff were to label food items with the date prepared or opened. At the beginning of each meal service, staff were to obtain tray line holding food temperatures and record them onto the Production Worksheet. Observations during the kitchen tour on December 8, 2024, at 9:23 a.m., revealed the following: In reach-in cooler #1, there were two chef salads, three opened bags of cheddar cheese, lettuce, shredded carrots, and an opened container of diced tomatoes that were not dated. There was dried food debris on the bottom of the cooler. In reach-in cooler #2, there was an opened bag of diced potatoes and parmesan cheese that were not dated. In reach-in cooler #3, there were three cups of dished crushed pineapple that were not dated. In reach-in cooler #6,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-10 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on December 8, 2024, at 11:00 a.m., the dietary manager stated the facility did not employ a certified dietary manager. In an interview conducted on December 10, 2024, at 11:30 a.m., the Administrator confirmed that there was not a full-time dietitian employed onsite at the facility and that the facility did not employ a qualified certified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.
- Potential for harm · E2024-12-10 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, review of facility documentation, observation, and staff interview, it was determined that the facility failed to follow the pre-approved menus. (Residents 16, 22, 208) Findings include: During the Resident Council interview conducted on December 9, 2024, at 10:30 a.m., four of four residents stated that food items at meals were often substituted without notice. Review of the facility menus revealed the lunch meal on December 8, 2024, was to include roasted potatoes, dinner roll, and fruit pie. The lunch meal on December 9, 2024, was to include fruit ambrosia salad. Observation of Resident 16 and Resident 208's lunch meal ticket on December 8, 2024, at 1:10 p.m., revealed that the meal should have included roasted potatoes, a dinner roll, and fruit pie. The residents received mashed potatoes, fruit ambrosia salad, and no dinner roll. On December 9, 2024, at 12:55 p.m., Resident 16 and Resident 22's meal ticket revealed that the meal should have included fruit ambrosia salad and the residents received applesauce. In an interview on December 10, 2024, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · D2024-12-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for four of 32 sampled residents. (Residents 16, 48, 132, 143) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included pressure ulcer of the sacral region. The Minimum Data Set (MDS) assessment dated [DATE], noted that the resident had a pressure area. The MDS Care Area Assessment (CAA) summary dated September 12, 2024, noted that the resident's pressure area was to be addressed in the care plan. There was no evidence that interventions to address Resident 16's pressure area were included in the current care plan. Clinical record review revealed that Resident 48 had diagnoses that included obstructive uropathy (build up of excess urine in the kidneys). The MDS assessment dated [DATE], noted that the resident had an indwelling catheter. The MDS CAA 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 · Dcited before2024-12-10 · 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 clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of 32 sampled residents. (Residents 16, 56) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included hypotension (low blood pressure). A physician's order dated June 7, 2024, directed staff to administer a medication (midodrine) three times a day every Monday, Wednesday, and Friday for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 130 millimeters of mercury (mmHg). Review of Resident 16's medication administration records (MARs) revealed that staff administered the medication seven times in November and four times in December 2024 when the resident's SBP was greater than 130 mmHg. Clinical record review revealed that Resident 56 had diagnoses that included cerebral infarction (sudden loss of blood flow to the brain), chronic kidney 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 · D2024-12-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented to prevent falls and that the physician was notified per facility policy for one of 32 sampled residents. (Resident 146) Findings include: Review of the facility policy entitled, Accidents/Incidents, last reviewed November 15, 2024, revealed that staff was to investigate all accidents and implement appropriate interventions based on conclusions, and that the physician would be notified of any unwitnessed fall. Clinical record review revealed that Resident 146 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis), and altered mental status. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment. Review of the care plan revealed Resident 146 was at risk for falls due to cognitive loss and lack of safety…
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 · D2024-12-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
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 that pharmacy recommendations were acted upon in a timely manner for two of 32 sampled residents. (Residents 79, 149) Findings include: Clinical record review revealed that Resident 79 was admitted to the facility on [DATE], with diagnoses that included Parkinsonism, dementia, and depression. Review of the clinical record revealed that the pharmacist made recommendations regarding Resident 79's medications on June 19, July 26, August 19, September 17, October 28, and November 30, 2024. There was no documentation to indicate what the recommendations were for June, July, August, or September, or that they were addressed by the physician. Clinical record review revealed that Resident 149 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse (fainting), hypertension (high blood pressure), and dementia. Review of the clinical record revealed that the pharmacist made…
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 · D2024-12-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to properly store medications in one of three nursing units. (Second Floor Nursing Unit) Findings include: Review of the facility policy entitled, Storage of Medication, last reviewed [DATE], revealed that staff were to note the date on the label for insulin vials and pens when first opened. Outdated, contaminated, discontinued, or deteriorated medications were to be immediately removed from stock and disposed of according to procedures for medication disposal. Observation of a medication cart used for resident rooms 218 through 229 on [DATE], revealed four insulin lispro pens that were opened and not labeled, one insulin glargine pen that was opened and not labeled, one Semglee insulin pen that was opened and not labeled, and one Basaglar insulin pen that was opened and not labeled. In an interview, the licensed practical nurse 1 (LPN 1) stated that the insulin pens should have been labeled with an…
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 · D2024-09-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a change in treatment for one of four sampled residents. (Resident 1) Findings include: Review of a facility policy entitled, Change in Condition: Notification of, last reviewed July 1, 2024, revealed that the center must immediately notify the resident's representative where there was a need to alter treatment significantly, which included commencement of a new form of treatment. Clinical record review revealed that Resident 1 had diagnoses that included respiratory failure, mild cognitive impairment, pulmonary disease, and anxiety disorder. On September 23, 2024, the nurse practitioner noted that the resident had increased shortness of breath (SOB), congestion, and wheezing, as well as SOB and fatigue at rest. The condition had not resolved with prior treatment. Review of a physician's order dated September 24, 2024, directed staff to administer azithromycin (an antibiotic) daily for five days. There was no evidence…
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 before2024-06-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 staff interview, observation, and facility policy review, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on three of three nursing units. (Second, Third, and Fourth floors) Findings include: In an interview on June 28, 2024, at 10:20 a.m., Dietary Employee 1 (DE 1) stated all foods were to be labelled with a date that the item was opened and processed meats were to be discarded seven days after the date opened. Observations during the kitchen tour on June 28, 2024, at 10:25 a.m., revealed the following: In dry storage, there was an opened plastic container of dry cereal that was not dated. In the reach-in dairy cooler, there was a container of strawberries that was not dated. In the reach-in juice cooler, there were two pans of sliced lemons that were not dated. In the cooks' cooler, there were two opened bags of diced ham and turkey lunch meat that were not dated. There was a pan of pancakes, individually wrapped in plastic and removed from the original packing that were not dated. There was a bag of opened hot…
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 before2024-01-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department. Findings include: Review of the facility's policy entitled, Refrigerated/ Frozen Storage, last reviewed November 3, 2023, revealed that all foods were to be labelled with a date received and prepared food items were to be dated. Observation during the kitchen tour on January 23, 2024, at 10:00 a.m., revealed that in the kitchen freezer, there were three bags of spinach removed from the original box and not dated. In the snack refrigerator, there was a tray of 14 dishes containing applesauce or fruit cocktail that were not dated. There was a dish of pureed fruit cocktail with a date of January 6, 2024. In the milk refrigerator, there were two containers of cottage cheese with a use-by date of January 19, 2024, and two containers of icing that were not dated. In the cook's refrigerator, there were two mislabeled chef salads. The coffee machine table had a bottom shelf that had multiple areas of peeling paint. The shelf had…
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 before2024-01-25 · 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 that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 27 sampled residents. (Residents 10, 32) Findings include: Clinical record review revealed that Resident 10 had diagnoses that included vascular dementia and major depressive disorder recurrent with psychotic symptoms. On November 29, 2023, the resident received a last dose of an anti-psychotic medication (Risperidone). The MDS assessment dated [DATE], indicated that the resident was still on an anti-psychotic medication. The MDS inaccurately reflected that the resident was still on an anti-psychotic medication during the assessment look back period of seven days. Clinical record review revealed that Resident 32 had diagnoses that included diabetes mellitus and muscle wasting. On November 25, 2023, the physician directed nursing to administer enteral nutrition via a tube. The MDS assessment…
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 before2024-01-25 · 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 clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 27 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included chronic kidney disease, hyperkalemia(high blood potassium), and anemia of chronic kidney disease. The resident had an arteriovenous (AV) fistula (an artificial tube used to connect an artery to a vein for hemodialysis) placed on the left arm in December 2021. On December 22, 2021, a physician's order directed staff to not obtain Resident 15's blood pressure or blood draws from the left arm related to the left arm AV fistula site. Review of Resident 15's blood pressure summary revealed that from December 22, 2023, through January 22, 2024, nursing had taken the resident's blood pressure in the left arm 25 of 96 times. In an interview conducted on January 25, 2024, at 10:00 a.m., the Director of Nursing confirmed that the staff should have taken Resident 15's blood pressure using the right arm. 28 Pa. Code…
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 · D2024-01-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide services and treatment to prevent a further decrease in range of motion and contractures for one of four sampled residents with limited range of motion. (Resident 62) Findings include: Clinical record review revealed that Resident 62 had diagnoses that included a stroke with left sided paralysis, dementia, abnormal posture and contracture of the muscle. The Minimum Data Set assessment dated [DATE], indicated that the resident had some memory impairment, required extensive assistance from staff for dressing and had limitations in range of motion in both lower extremities. Review of an occupational therapy Discharge summary dated [DATE], revealed that there was a recommendation for staff to apply a left lower extremity bean bag splint at all times. Review of the care plan identified the resident had a self care deficit related to activities of daily living due to physical limitations due to 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 · Fcited before2023-09-15 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on September 15, 2023, at 1:05 p.m., the Director of Nursing (DON), stated that the facility did not currently employ a certified dietary manager. The DON also stated that there was not a full time registered dietitian at the facility. There was no evidence that the facility employed a certified dietary manager in the absence of a full time qualified dietitian. 28 Pa Code 201.18(e)(1)(6) Management.
- Potential for harm · E2023-09-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, resident interview, and results of a test tray audit, it was determined that the facility failed to provide food that was palatable and at appetizing temperatures on two of three nursing units. (Station two and Station four) Findings include: Review of the facility policy entitled, Meal Service, effective May 1, 2023, revealed that meals are to be served accurately, timely, and at the appropriate temperatures. On September 15, 2023, from 11:00 a.m. through 11:30 a.m., Residents 2, 4, 5, and 6 stated that their meals are consistently cold. Results of a test tray audit conducted on September 15, 2023, at 12:15 p.m., revealed meatloaf with gravy at a temperature of 119 degrees Fahrenheit (F), scalloped potatoes at a temperature of 139 degrees F, and green beans at a temperature of 109 degrees F. The meatloaf and green beans were cool to taste. On September 15, 2023, from 12:45 p.m. through 1:00 p.m., Residents 2 and 5 were in their rooms with their lunch trays in front of them and Resident 7 was in the dining room with her lunch tray 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 · E2023-09-15 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — the official record, unedited, may be distressing
Based on a review of the facility's meal schedule, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with the resident needs on one of three nursing units. (Station 2) Findings include: Review of the facility's meal schedule revealed that the scheduled times for lunch on the Station two nursing unit was 11:10 a.m. and 11:25 a.m. On September 15, 2023, from 11:00 a.m., through 11:30 p.m., and at 12:55 p.m. Residents 2, 4, 5, 6, and 7 stated that their meals always arrrived late. On September 15, 2023, the unit manager of station 2 (RN1) stated that lunch was scheduled for 11:10 a.m. and 11:25 a.m. Observation on Station 2 nursing unit, on September 15, 2023, revealed Residents 2, 4, 5, 6, and 7 received their lunch trays at 12:45 p.m. through 1:00 p.m., over an hour past the scheduled meal times.
- Potential for harm · Dcited before2023-09-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to three of seven sampled residents. (Residents 2, 5, 6) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included congestive heart failure and diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and required staff assistance for bathing. The resident was to receive a shower twice per week. During an interview on September 15, 2023, at 11:30 a.m., the resident reported that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 2 stated that she would not refuse the opportunity to shower and had requested that staff wake her up to shower if she were sleeping. Review of documentation in the clinical record revealed that the resident was not offered a shower nine of nine scheduled…
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 · D2023-09-15 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility policy review, review of facility documentation, and interview, it was determined that the facility failed to promptly act upon a resident grievance for one of four sampled residents. (Resident 2) Finding include: Review of the facility policy entitled, Grievance/Concern, last reviewed July 19, 2023, revealed that the facility was to assure prompt receipt and resolution of a resident's grievance. Review of facility documentation revealed that on July 21, 2023, Resident 2 submitted a concern form regarding her blanket that was not returned from the laundry. Further review of the concern form revealed no documented follow up action. In an interview on September 15, 2023, at 12:30 p.m., Resident 2 stated that the facility has still not addressed her missing blanket. In an interview on September 15, 2023, at 1:15 p.m., the Director of Nursing confirmed that there was no documentation to support that the facility promptly acted upon Resident 2's grievance.
- Potential for harm · D2023-09-15 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, observation, and interview, it was determined that the facility failed to ensure that a resident's preference at meal times had been accommodated for two of seven sampled residents. (Residents 2, 7) Findings include: Review of the facility's weekly menu revealed that the lunch meal for September 15, 2023, was meatloaf with gravy, green beans, lyonnaise potatoes, and a seasonal fruit cup. Clinical record review revealed that Resident 2 was admitted to the facility with diagnoses that included diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and able to make her needs known. Resident 2's ongoing care plan revealed she had an altered nutrition status and interventions were to honor her food preferences and provide salt free seasoning packets with her meals. During an interview on September 15, 2023, at 11:10 a.m. Resident 2 stated that she does not receive condiments, meal items, or water as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2024-12-10 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s) from the facility, including the reasons for the moves and Ombudsman information, in writing upon transfer for eight of eight sampled residents who were transferred to the hospital. (Residents 39, 85, 89, 94, 95, 143, 146, 157) Findings include: Clinical record review revealed that Resident 39 was transferred to the hospital on October 25 and November 7, 2024, after changes in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfers to the hospital. Clinical record review revealed that Resident 85 was transferred to the hospital on July 9, September 1 and 13, and October 2, 2024, after changes in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfers to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-12-10 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, it was determined that the facility failed to post accurate and current nurse staffing information. Findings include: During a tour of the facility conducted on December 8, 2024, at 9:05 a.m., the staffing information that was posted in the lobby was dated for December 6, 2024. In an interview on December 10, 2024, at 10:00 a.m., the Administrator confirmed that incorrect staffing data was posted. 28 Pa Code 201.18(b)(3) Management.
- No harm found · C2024-12-10 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on December 8, 2024, at 9:45 a.m., revealed multiple pieces of crushed plastic and cardboard debris, crushed Styrofoam containers, and used gloves around the outside of both dumpsters. One dumpster had two lids on top of it, one of the lids was wide open and the other lid had two full bags of garbage on top of it. 28 Pa Code 201.18(b)(3) Management.
- No harm found · Ccited before2024-01-25 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, it was determined that the facility failed to notify the residents and the residents' representatives regardless of transfers from the facility and reasons for the moves in writing for six of nine sampled residents who were transferred to the hospital. (Residents 19, 28, 32, 79, 81, 123) Findings include: Clinical record review revealed that Resident 19 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 28 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 3 of 5 | 3.5 | -0.5 vs chain |
The other 183 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 183; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GENESIS PM PA OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/15/2022 |
| FC-GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| GHC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| SUN HEALTHCARE GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| WHITMAN, ARNOLD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 11/15/2022 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| MITCHELL, DARWIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/25/2023 |
CMS files one row per role, so the 15 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 395351. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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 →
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