Harmony Hills Healthcare And Rehabilitation Center
194 Swinderman Road, Wexford, PA 15090 · For profit - Corporation · 55 certified beds · (724) 935-3781 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 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 improved from 1 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 | 5.1% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.1% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 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 | 8.7% | 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 | 7.1% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.2% | 17.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.7% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.8% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.3% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.4% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.9% | 68.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.7% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.9% | 9.5% | 12.0% | typical |
§ 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.
48.5% 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 56 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.2% 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 31 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 0.80 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 29% 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 | 48.5%CMS range 37.7–62.8 | 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 | 11.2%CMS range 7.8–17.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.2% | 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 | 51.6% | 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 | 35.5% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 95.5% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.1% | 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 | 6.3%CMS range 3.4–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 55 beds and averages 49.6 residents a day — about 90% occupied, or roughly 5 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 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.81 hrs/resident/day on weekends vs 4.15 on weekdays — 8% thinner on weekends. RN hours go from 0.78 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · Ecited before2026-02-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for nine of twelve residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).Findings include: The facility policy Medication Administration - General Guidelines last reviewed 2/1/26, indicated The individual who administers the medication dose records the administration on the resident's MAR (medication administration record) directly after the medication is given. Review of Resident R1's MAR (medication administration record) for February 2026, revealed an order for oxycodone 5mg (a narcotic pain medication used to treat moderate to severe pain) to be given every six hours as needed for pain. Ten administrations were documented on the MAR from 2/5/26, through 2/27/26. Review of Resident R1's Controlled Substance Record indicated that 15 additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 2/6/26, 2/7/26, 2/12/26, 2/14/26,…
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 before2025-07-17 · 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 review of facility policy, observations and staff interview, it was determined that the facility failed to maintain sanitary conditions and practice proper infection control which created the potential for cross contamination and food borne illness (Main Kitchen) the facility failed to properly monitor refrigerator temperatures on one of two nursing units (C & D Hall unit) and failed to properly monitor residents in room personal refrigerator temperatures for three of three residents (Resident R20, R23, R50) which created the potential for food borne illness. Review of facility policy Environment dated 1/13/25 indicates all food preparation areas, and dining areas will be maintained in a clean and sanitary condition. Review of the facility policy Resident's Private Refrigerators last reviewed 1/13/25, indicated residents’ private refrigerators will be cleaned to maintain proper infection control. Monitor temperature daily and document on log. Findings include: During an observation of the main designated kitchen on 7/15/25, at 9:05 a.m. the following was observed: - fan on…
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 · E2025-07-17 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for three of five residents (Resident R2, R31, and R43). Findings include:The facility Participation in Planning Care and Treatment policy dated 1/13/25, indicated that the resident and their family or responsible party have the right to participate in planning care and treatment or changes in care and treatment. The resident care plan shall be reviewed, evaluated, and updated quarterly and as necessary by the interdisciplinary team involved in the care of the resident. The resident and their representative shall be notified of care plan meetings and care conference and offered the opportunity to attend in person or via phone. Review of Resident R2's admission record indicated resident was admitted on [DATE]. Review of Resident R2's 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 · E2025-07-17 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
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 make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with hospital transfers (Residents R3, R6, and R43) and failed to obtain a physician order for discharge to home for one of six residents (Resident R56). Findings include: Review of facility policy Documentation of Resident Discharge last reviewed 1/13/25, indicated documentation in Point Click Care will be completed when resident is discharged from the facility. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident 3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/25, indicated diagnoses of acute pancreatitis (condition where the pancreas becomes inflamed), diabetes mellitus and hypertension (force of blood pushing against the artery walls is consistently too high).…
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 · D2025-07-17 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 interviews, it was determined the facility failed to conduct a significant change assessment for one of two residents reviewed (Resident R37).Findings include:According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS - a periodic assessment of care needs) assessments dated October 2024, the facility must conduct a comprehensive assessment of a resident within fourteen days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition. The RAI Manual indicates a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident'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 · D2025-07-17 · 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 review of facility policy, record review, resident and staff interviews, and observations it was determined that the facility failed to provide a resident environment free of potential accidental hazards for one of three residents (Resident R21).Findings include: Review of the facility policy Incident and Accident dated 1/13/25, indicated the facility shall make every effort to ensure that the resident's environment remains as free of accidental hazards as is possible. Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/7/25, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), renal insufficiency (poor function of the kidneys), and high blood pressure. Review of Resident R21's clinical record on 7/15/25, at 9:00 a.m. failed to include an assessment, identify the risks (burns and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R19).Findings include: Review of facility policy Colostomy Care and Management dated 1/13/25, indicated the facility will ensure the safe, effective, and person-centered care and management of residents with colostomies. Use appropriate pouching system based on stoma (opening in the abdomen), output type, and skin sensitivity. Stoma type, pouching and wafer system including size shall be documented in the medical record. Review of the clinical record revealed that Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/10/25, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and colostomy (surgery to divert…
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 · D2025-07-17 · 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, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility for one of three residents (Resident R2).Findings include: The facility policy Pharmacy Services reviewed 1/13/25, indicated the facility will provide routine and emergency drugs and biologicals to the residents, or obtain them under an agreement and will be provided in a timely manner. Drug regimen review to include: - - A licensed pharmacist will review the drug regimen of each resident at least once a month.- - The pharmacist will report any irregularities to the attending physician and the Director of Nursing. Review of Resident R2's admission record indicated resident was admitted on [DATE]. Review of Resident R2's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/26/25, indicated diagnoses of depression, migraines (headache), and paraplegia (paralysis of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (C and D Hall Medication Cart) and failed to store drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (C and D Hall Medication Room).Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (C and D Hall Medication Cart), failed to store drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (C and D Hall Medication Room) and failed to maintain documentation of medication refrigerator temperatures in one of two medication rooms (C and D Hall medication refrigerator). Findings include: Review of the facility policy Storage of Medications last reviewed 1/13/25, indicated that medications and biologicals are stored safely, securely, and properly.…
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 · D2025-07-17 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of four residents ordered an NPO (nothing by mouth) diet (Resident R6). Findings include: Review of the facility policy Nothing by Mouth reviewed 1/13/25, indicated the facility will ensure the safety and well-being of residents who are at risk for aspiration or other swallowing-related complications by strictly enforcing NPO orders as directed by the physician. No food, liquid, or medication shall be administered by mouth to any resident who is under an active NPO status unless otherwise recommended by the Speech-Language Pathologist or ordered by the physician. All staff must strictly adhere to NPO orders. No staff member may provide anything by mouth unless it is explicitly ordered by the physician. Review of the clinical record revealed that Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic…
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 19 citations
- Potential for harm · D2025-07-17 · 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 observations, resident and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for one out of five residents (Resident R57). During an interview on 7/15/25, at 11:30 am Resident R57 voiced a concern that she is a vegetarian, doesn't drink milk. She feels her dietary needs are not being met.Review of the admission record indicated Resident R57 was admitted to the facility on [DATE].Review of Resident R57's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/25, indicated the diagnoses of fracture of right femur, falls and neuropathy (damage or disease affecting nerves, typically in the peripheral nervous system, which lies outside the brain and spinal cord). Review of nutritional assessment dated [DATE] indicated resident is a vegetarian, no milk has a surgical incision indicating that she requires 64 gm of protein a day.Lunch on 7/15/25 per menu consisted of ham, sweet potatoes, greens beans and pears. Resident R57…
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 · D2025-07-17 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two residents (Resident R37).Findings include: Review of facility policy Hospice Care Policy dated 1/13/25, indicated the facility will coordinate and deliver hospice care services in partnership with contracted hospice providers, ensuring residents receive compassionate, appropriate, and compliant end of life care in accordance with federal and state regulations, facility policies, and the resident's plan of care. Review of the admission record indicated Resident R37 admitted to the facility on [DATE]. Review of Resident R37's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/28/25, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to…
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 before2025-07-17 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of three quarterly meetings (Quarter One of 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Committee Charter policy dated 1/13/25, indicated the purpose of QAPI is to utilize a method of proactive, data-driven systematic and comprehensive process to monitor performance that identifies trends and opportunities for improvement. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter One of 2025, failed to reveal the Medical Director was in attendance. During an interview on 7/17/25, at 9:54 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of three quarterly meeting (Quarter One 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 before2025-07-17 · 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, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R2).Findings include: Review of the facility policy Wound Care last reviewed 1/13/25, indicated to provide guidelines for the care of wounds to promote healing. Steps in the procedure include but not inclusive to loosen tape and remove dressing and discard. Wash and dry hands thoroughly. Review of the facility policy Hand Hygiene last reviewed 1/13/25, indicated the facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection. Hand hygiene is indicated but not inclusive to completion before moving from work on a soiled body site to a clean body site, after contact with blood, body fluids, or contaminated surfaces. Review of Resident R2's clinical record indicated admission to the facility on 8/11/23.…
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 before2024-10-18 · 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 a review of policy, observations, and staff interviews, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to properly label, date, and store food products in the kitchen refrigerator and basement freezer creating the potential for unsafe conditions and the potential for cross contamination in the main kitchen, basement freezer storage area and in one of two kitchenettes (C and D level kitchenette). Findings include: A review of the facility Labeling and Dating Inservice, last reviewed 6/17/24, indicates policy statement: Healthcare Service Group, Inc., and its subsidiaries (HCSG) promotes the health and safety of all employees, as well as that of the clients and residents we serve. Proper labeling and dating ensure that all foods are stored, rotated, and utilized in a first in first out manner. All foods should be dated upon receipt before being stored. A review of the facility Food storage: cold foods last reviewed 6/17/24, indicates all foods will be stored wrapped or in covered containers, labeled and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-18 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for six of 10 residents (Residents R5, R17, R28, R35, R44, and R47). Findings include: Review of facility policy MDS/RAI/Care Plan dated 6/17/24, indicated the Resident Assessment Instrument (RAI) and Care Planning Process provide a tool for an interdisciplinary approach to plan the care of the resident. The purpose of the RAI is to incorporate the identified medical, nursing, nutritional, rehabilitative, and psychosocial needs of each resident into interventions and goals to meet those needs. The RAI is a process that defines an interdisciplinary approach to resident assessment and plan of care to help resident attain the highest practicable functional level. The facility will develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strengths, problems, and needs.…
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 before2024-10-18 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 review of facility policies, observations, and staff interviews it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts (first floor B hall medication cart), one of two medication rooms (first floor medication room) and properly secure stock medications in the central supply area. Findings include: A review of the facility Storage of Medications, last reviewed [DATE], indicates medications are stored in a safe, secure, and orderly manner. Compartments containing medications are locked when not in use. Medications are stored in an orderly manner in cabinets, drawers, or carts. A review of the facility Medication Administration, last reviewed [DATE], indicates medications are administered at the time they are prepared. A review of the State Operations Manual Rev., 225: issued [DATE], §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature…
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 · E2024-10-18 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for three of ten residents (Resident R17, Resident R25, and Resident R29). Findings include: Review of facility Binding Arbitration Agreement policy reviewed on 6/17/24, indicated residents or representatives are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents or their representatives have the right to make informed decisions about important aspects of their health,…
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 · D2024-10-18 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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, facility policy, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents with facility-initiated transfers (Residents R21 and R28). Findings include: Review of facility policy Documentation of Resident Discharge and Deaths dated 6/17/24, indicated to complete the resident transfer form and provide a photocopy of the following: resident face sheet, advance directive, medication administration record, current history and physical, current month's physician and verbal orders, pertinent diagnostic testing, and enter the name of each item sent as an attachment on the transfer form. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/24/24, indicated diagnoses of high blood pressure, hyperlipidemia (high…
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 · D2024-10-18 · 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 a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of three residents (Resident R31). Findings include: Review of facility policy MDS/RAI/Care Plan dated 6/17/24, indicated during the first five days of a resident's admission or readmission to the facility the Registered Nurse Assessment Coordinator (RNAC) will establish an assessment date for the Initial Assessment and distribute a schedule to the Interdisciplinary Team. The assessment reference date (ARD) will be set to reflect an accurate reflection of the resident's care needs within a specific reference period. The RNAC will establish a schedule for each subsequent assessment and review changes in residents as they occur and determine if a Significant Change is clinically warranted. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for…
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 · D2024-10-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of three residents (Resident R23) to accurately reflect the current status of the resident and care needs. Findings include: Review of facility policy MDS/RAI/Care Plan dated 6/17/24, indicated the Resident Assessment Instrument (RAI) and Care Planning Process provide a tool for an interdisciplinary approach to plan the care of the resident. Residents will have a comprehensive care plan completed and reviewed within seven days of the completion date of the Minimum Data Set (MDS). The resident will be assessed at least quarterly and care plan reviewed by the interdisciplinary team. Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/31/24, indicated admission to the facility on 7/25/24 with the diagnosis of the diagnoses of heart failure (heart doesn't pump blood as well as it should), hypertension (high blood pressure), and left side hemiplegia (paralysis that affects one side of the body) Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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 review of facility policy, clinical closed record review, and staff interviews, it was determined that the facility failed to ensure a resident had a physician discharge order to return home for one of three residents (Closed Record (CR) Resident R53) and failed to ensure a resident had a physician order for care and management of an over the bed trapeze bar for one of three residents (Resident R47). Findings include: Review of facility policy Documentation of Resident Discharge and Deaths dated 6/17/24, indicated documentation will be completed when a resident is discharged from this facility. Notification to attending physician, noting order for discharge. The following items are to be documented when a resident is discharged from the facility- Physicians Discharge order has been obtained. Review of the facility policy Transcribing Physician Orders dated 6/17/24, indicates physician orders will be transcribed when they are received. Review of CR Resident R53's Minimum Data Set (MDS-periodic 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 · D2024-10-18 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for two of five nurse aide personnel records (Nurse aide Employee E6 and Nurse aide Employee E7). Findings include: The facility Performance Evaluations policy reviewed 6/17/24, indicated that the job performance of each employee shall be reviewed and evaluated at least annually. Review of Nurse aide (NA) Employee E6's personnel record indicated she was hired to the facility on 3/18/22. Review of NA Employee E6's personnel record for the evaluation period of 3/18/23 to 3/18/24, did not indicate a performance review with the employee was completed. Review of NA Employee E7's personnel record indicated she was hired to the facility on 8/1/22. Review of NA Employee E7's personnel record for the evaluation period of 8/1/23 to 8/1/24, did not indicate a performance review with the employee was completed. During an interview on 10/16/24, at 11:15 a.m. the Director of Nursing confirmed that the facility failed to complete annual…
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 before2024-10-18 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meeting (December 2023 through February 2024). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 6/17/24, indicated that the facility shall develop, implement, and maintain an ongoing, facility-wide, date-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Review of Quality assurance and performance improvement sign in sheets and attendance records indicated the facility failed to provide evidence that the facility conducted a March 2024 QAPI meeting. During an interview on 10/18/24, at 12:52 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct QAA meetings at least quarterly with all the required committee members for one of four quarterly meeting…
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 before2024-08-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, resident and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for one of four sampled residents (Residents R1). This deficiency is cited as past non-compliance. Findings include: The facility Medication packaging policy dated 6/17/24, indicated that medications are provided in packaging to facilitate accurate administration and accountability of medication. It is suggested that nurses review the medication administration records (MAR) prior to passing medications in order to prevent errors. Review of Residents R1's admission record indicated she was admitted on [DATE]. Review of Residents R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 5/18/24, indicated that she had diagnoses that included paraplegia (paralysis of the legs and lower body), anxiety disorder (a medical condition creating 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 · D2023-11-16 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for three of three residents (Residents R10, R12 and R23). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(n) - Bed Rails states that the facility must assess the resident for risk of entrapment from bed rails prior to installation. Additionally, there should be evidence in the resident's records that the facility performed ongoing assessments to assure that the bed rail is used to meet the resident's needs and that there is an ongoing evaluation of risks associated with bed rail usage. Review of the facility policy Proper Use of Side Rails dated 5/1/23, indicated An assessment will be made to determine the resident's symptoms or reason for using side rails. The use of quarter or half rails, as an assistive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-16 · 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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R3). Findings include: Review of the facility Wound Care policy dated 9/2017, last reviewed on 5/1/23, indicated to treat wound as ordered, apply new dressing without touching or contaminating the wound bed (open part of the wound). Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of R3's Minimum Data Set (MDS-periodic assessment of care needs) dated 8/23/23, included diagnoses of high blood pressure, anemia (the blood doesn ' t have enough healthy red blood cells), and heart failure (heart doesn ' t pump blood as well as it should). Review of Resident R3's physician order dated 11/12/23, indicated Cleanse bilateral gluteal folds (skin crease separating the upper thigh from the buttock) with soap and water, pat dry.…
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 · C2023-11-16 · tag F0558 — failed to accommodate residents' needs and preferences — widespreadReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on resident and staff interview it was determined that the facility failed to have a beautician available to meet resident needs for the facility. Findings include: During an interview on 11/15/23, at 10:35 a.m. Resident R18 indicated that it beautician is not frequently available. During a follow up interview on 11/16/23 at 10:54 a.m. Resident R18 indicated that they were suppose to get their hair done last week but that did not take place. During an interview on 11/16/23, at 11:14 a.m. Director of Activities Employee E6 confirmed that the facility has a beautician but they are onsite every 6 weeks for several hours only. Director of Activities Employee E6 confirmed that the facility failed to offer beautician available to meet resident needs. 28 Pa. Code 201.29(i)Resident rights.
- No harm found · B2023-11-16 · 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 — the official record, unedited, may be distressing
Based on review of facility documentation, resident and staff interview it was determined that the facility failed to offer all residents the opportunity to vote for the May and November 2023 elections. Findings include: Review of the resident council minutes for five months (October, September, August, July and June 2023) failed to include information about how the facility ask's residents if they are interested in voting. During a Resident group on 11/15/23, at 10:30 a.m. two residents stated they did not get to vote in the November and May elections. Both of the residents stated they were interested in voting. During an interview on 11/16/23, at 2:21 p.m. Director of Activities Employee E6 confirmed that the facility could not provide documentation showing all residents were asked to vote in the May and November election and that the facility failed to offer all residents the opportunity to vote. 28 Pa. Code 201.1(i)Resident rights.
“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.
Who owns this facility
CMS ownership filings flag an owner of this facility as a private-equity firm. That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.
- LIMESTONE ENTERPRISES LLC — private equity · 67.00% share · 5% Or Greater Direct Ownership Interest
Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LIMESTONE ENTERPRISES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 67% | since 03/19/2024 |
| GESTETNER, ELLIOTT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/19/2024 |
| MOSKOWITZ, YISROEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 30% | since 01/21/2025 |
| GEM FAMILY 2020 NGCG NEVADA TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 67% | since 03/19/2024 |
| CAPITAL FUNDING LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 03/19/2024 |
| GESTETNER, COLEV | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/21/2025 |
| MEYER, DAMON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/21/2025 |
| ROSCOE, BRANDON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/21/2025 |
| GESTETNER, MIRIAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/28/2025 |
| CAM-ELM COMPANY LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| MTL HEALTHCARE LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| OCEAN FISCAL SERVICES LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| SMV INTERMEDIATE HOLDINGS I-B LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| SMV INTERMEDIATE HOLDINGS II LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| SMV INTERMEDIATE HOLDINGS III LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| SMV INTERMEDIATE HOLDINGS IV LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| SMV PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| SMV REAL ESTATE HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| SMV WEXFORD LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| UB LLC | Organization | ADP OF THE SNF | — | since 01/21/2025 |
| COHEN, CHAYA | Individual | ADP OF THE SNF | — | since 01/21/2025 |
| KROHN, SIMCHA | Individual | ADP OF THE SNF | — | since 01/21/2025 |
| SCHRON, AVI | Individual | ADP OF THE SNF | — | since 01/21/2025 |
CMS files one row per role, so the 32 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
14 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 72% 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 $243K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395903. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-17, 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.