Home / Pennsylvania / Ebensburg
429 Manor Drive, Ebensburg, PA 15931 · Cambria County · (814) 472-8100
301 certified beds, about 169 residents a day · For profit - Corporation · Medicare and Medicaid since 1990
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395828 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on November 20, 2025, inspectors cited 19 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
Of 107 health citations since September 2023, 5 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 2 fines totaling $59,576 in the last three years; the largest was $46,982, and the latest is dated November 18, 2025.
Nurses and nurse aides worked 3.25 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.44 of those hours.
50.4% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).
CMS links it to Saber Healthcare Group, an affiliated group of 126 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 107 health citations on file.
Inspectors wroteBased on a review of policies, clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of five residents reviewed (Resident 2). This deficiency was cited as past non-compliance.
Inspectors wroteBased on a review of policies, clinical record review and staff interviews, it was determined that the facility failed to develop and implement a discharge planning process to align with the resident's goals and failed to provide discharge instructions, including medication times and doses for one of five residents reviewed (Resident 3).
Inspectors wroteBased on review of facility policy, manufacturer's instructions, US Consumer Product Safety Division warnings, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the environment was free from accident hazard, placing the safety of the residents in an Immediate Jeopardy situation by not adequately securing water absorbing beads from residents on the dementia unit who wander, resulting in the ingestion and ICU hospitalization for one resident (Resident 1).
Inspectors wroteBased on review of employee job descriptions, as well as observations and staff interviews, it was determined that the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical well being of residents in the facility by failing to ensure that water absorbing beads were secured, placing the residents on the dementia unit at risk for serious harm which created an Immediate Jeopardy situation.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition in the facility's kitchen.
Inspectors wroteBased on review of state laws, facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for ten of 51 residents reviewed (Resident 3, 40, 44, 46, 52, 87, 96, 99, 115, and 158).
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 51 residents reviewed (Resident 2, 4, 11, 16, 17, 115, 157).
Inspectors wroteBased on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food that was palatable and at appetizing temperatures.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to inform the resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for two of 51 residents reviewed (Residents 1 and 16). Findings Include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 8, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnosis that included chronic obstructive pulmonary disease (COPD- condition involving constriction of the airways and difficulty or discomfort in breathing). [...]
Inspectors wroteBased on review of a policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 51 residents reviewed (Resident 18).
Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 51 residents reviewed (Resident 142).
Inspectors wroteBased on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed for one of 51 residents reviewed (Resident 173).
Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 51 residents reviewed (Residents 18 and 38).
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of 51 residents reviewed (Residents 23, 28, 38, and 129).
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medications and treatment administration were followed for 12 of 51 residents reviewed (Residents 3, 4, 40, 44, 46, 52, 87, 96, 99, 115, 157, and 158).
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for two of 51 residents reviewed (Resident 15, 23) who were at risk for falls.
Inspectors wroteBased on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that a dialysis emergency kit was at the resident's bedside for two of 51 residents reviewed (Residents 10 and 11).
Inspectors wroteBased on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for three of 51 residents reviewed (Residents 12, 46, 157).
Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.
Inspectors wroteBased on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for four of 51 residents reviewed (Residents 17, 23, 36 and 46).
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper medication handling procedures were followed, and that proper infection control practices were followed for one of 18 residents reviewed (Resident 9).
Inspectors wroteBased on review of facility policy and clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 10 residents reviewed (Resident 4).
Inspectors wroteBased on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 10 residents reviewed (Resident 1).
Inspectors wroteBased on review of state laws, facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for one of 10 residents reviewed (Resident 1).
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of ten residents reviewed (Resident 8).
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of ten residents (Resident 2). Findings Include:The facility's policy regarding elopement, dated December 30, 2024, indicated that if staff discover a resident is missing a head count will be completed, and if the resident is unable to be found a code green will be announced. The designee will notify the administrator, director of nursing, and the attending physician. If the resident is not found in a reasonable period of time the local emergency responders will be notified. A social services admission note for Resident 2 dated July 10, 2025, revealed that the resident was admitted from the hospital. [...]
Inspectors wroteBased on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for 14 of 14 residents reviewed (Residents 1,2,3,4,5,6,7,8,9,10,11,12,13 and 14). This deficiency is being cited as past non-compliance.
Inspectors wroteBased on review of policies and clinical records, as well as staff and resident interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for three of 14 residents reviewed (Residents 2, 7 and 14). This deficiency is being cited as past non-compliance.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician-ordered 15-minute safety checks were completed for one of 10 resident's reviewed (Resident 5).
Inspectors wroteBased on review of facility , as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for handling linen.
Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were provided to prevent infection for one of eight residents reviewed (Resident 2).
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for five of 11 residents reviewed (Residents 7, 8, 9, 10, 11).
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if residents were safe to self-administer medications for one of 11 residents reviewed (Resident 1).
Inspectors wroteBased on review of clinical records and employee records, as well as staff interviews, it was determined that the facility failed to maintain an environment free of potential safety hazards related to resident transportation to appointments for one of 11 residents (Resident 6).
Inspectors wroteBased on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors due to receiving another resident's medications for one of five residents reviewed (Resident 5) resulting in an admission to the intensive care unit.
Inspectors wroteBased on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for three of 66 residents reviewed (Residents 58, 130, 134). This deficiency is being cited as past non-compliance.
Inspectors wroteBased on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 66 residents reviewed (Residents 12, 17, 18, 25, 41, 93, 122).
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for seven of 66 residents reviewed (Residents 2, 25, 41, 64, 79, 106, 130).
Inspectors wroteBased on a review of facility policies and clinical records, as well as resident family and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for one of 66 residents reviewed (Resident 9).
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 66 residents reviewed (Residents 44, 149).
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition in the facility's kitchen.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that assistance with hygiene was given in a manner that maintained dignity for one of 66 residents reviewed (Resident 84).
Inspectors wroteBased on review of residents' clinical records and facility's grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to honor the resident's right to make informed choices and participate in his/her treatment for one of 66 residents reviewed (Resident 79).
Inspectors wroteBased on review of policies, clinical records, and facility grievance forms, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve the grievances of residents for one of 66 residents reviewed (Resident 18).
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice was provided to the resident's responsible party regarding the reason for transfer to the hospital for three of 66 residents reviewed (Residents 12, 32, 84).
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for five of 66 residents reviewed (Residents 141, 143, 147, 152, 165).
Inspectors wroteBased on a review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 66 residents reviewed (Resident 94).
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included specific and individualized interventions for one of 66 residents reviewed (Resident 44).
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify an order for treatment for one of 66 residents reviewed (Resident 69).
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that discharge instructions that included post-discharge medications and a post-discharge plan of care was completed for one of three discharged residents reviewed (Resident 149).
Inspectors wroteBased on review of clinical records and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 66 residents reviewed (Resident 44), and failed to follow recommendations from a interventional radiology consultation for one of 66 residents reviewed (Resident 79).
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 66 residents reviewed (Residents 64, 120).
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician and the Certified Registered Nurse Practitioner (CRNP - a registered nurse with advanced training) wrote, signed, and dated progress notes with each visit for two of 66 residents reviewed (Residents 79, 84).
Inspectors wroteBased on a review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of medications with the date they were opened in one of four medication carts observed (First-Floor Southeast medication cart).
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure timely completion of prescribed laboratory services for two of 66 residents reviewed (Residents 58, 120).
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 66 residents reviewed (Resident 18) and failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 66 residents reviewed (Resident 84).
Inspectors wroteBased on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 66 residents reviewed (Resident 79).
Inspectors wroteBased on a review of the facility's meal schedule, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times on the nursing unit.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions.
Inspectors wroteBased on review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for residents residing on the secured memory impaired unit for one of 15 residents reviewed (Resident 14), placing the safety of current residents in Immediate Jeopardy.
Inspectors wroteBased on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of accident hazards.
Inspectors wroteBased on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of six residents reviewed (Residents 2, 4).
Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards of food service safety by failing to properly label and date frozen and refrigerated foods.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff used proper infection control techniques during incontinent care for two of six residents reviewed (Residents 5, 6).
Inspectors wroteBased on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 10 residents reviewed (Resident 2) that resulted in facial bruising from being kicked repeatedly.
Inspectors wroteBased on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that allegations of physical abuse were reported in a timely manner for one of 10 residents reviewed (Resident 2).
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after an injury occurred for one of 10 residents reviewed (Resident 2).
Inspectors wroteBased on review of facility policies and personnel records, as well as staff interviews, it was determined that the facility failed to ensure that reference checks were obtained prior to hire for four of five new employees reviewed (Nurse Aides 3 and 4, Licensed Practical Nurse 5, Registered Nurse 6).
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for six of 65 residents reviewed (Residents 16, 55, 118, 123, 129, 130).
Inspectors wroteBased on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 65 residents reviewed (Residents 21, 41, 51, 90, 113).
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the Certified Registered Nurse Practitioner/physician wrote, signed, and dated progress notes with each visit for one of 65 residents reviewed (Resident 8).
Inspectors wroteBased on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.
Inspectors wroteBased on clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents' drink preferences were honored for 16 of 65 residents reviewed (Residents 3, 10, 25, 38, 41, 45, 51, 65, 67, 87, 98, 102, 105, 106, 112, 117).
Inspectors wroteBased on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served under sanitary conditions, in accordance with professional standards for food service safety, and failed to ensure that food items were stored in accordance with professional standards for food service safety in three of three nursing unit pantry refrigerators (first, third, fourth floor pantries).
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified about the need to alter treatment for one of 65 residents reviewed (Resident 51).
Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 65 residents reviewed (Resident 33).
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for three of 65 residents reviewed (Residents 45, 47, 77).
Inspectors wroteBased on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of two of 65 residents reviewed (Residents 57, 109).
Inspectors wroteBased on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by failing to follow physician's orders and care-planned interventions for one of 65 residents reviewed (Resident 119) who was at risk for skin breakdown.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 65 residents reviewed (Resident 33).
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a physician performed the initial comprehensive visit with the resident for one of 65 residents reviewed (Resident 96).
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 65 residents reviewed (Resident 113).
Inspectors wroteBased on review of manufacturer's instructions and facility policy, as well as observations and staff interviews, it was determined that the facility failed to label medication when opened for one of two medication storage rooms reviewed.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications.
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that nursing services provided met professional quality of standards for one of 14 residents reviewed (Resident 6). This deficiency was cited as past non-compliance.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a gastroenterologist (a medical doctor who specializes in conditions affecting your digestive system) for one of 14 residents reviewed (Resident 8).
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to investigate injuries of unknown origin to rule out abuse or neglect for one of five residents reviewed (Resident 2) who suffered a fracture of the wrist.
Inspectors wroteBased on review of policies, clinical records, and information provided by the facility, as well as family and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve the grievances of residents and/or their legal representatives and ensuring that a written copy of the grievance/complaint decision was provided to the resident and/or resident representative for one of 11 residents reviewed (Resident 4).
Inspectors wroteBased on review of Pennsylvania's Nurse Practice Act, policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician's orders were clarified for tracheostomy care for one of the 11 residents reviewed (Resident 2).
Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions.
Inspectors wroteBased on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's plan of care was followed for fall prevention and transfers for one of 14 residents reviewed (Resident 2) resulting in a fracture. This deficiency was cited as past non-compliance.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of 15 residents reviewed (Resident 4).
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 14 residents reviewed (Resident 5).
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of nine residents reviewed (Resident 2) and failed to clarify a physician's order for one of nine residents reviewed (Resident 4).
Inspectors wroteBased on facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for one of nine residents reviewed (Resident 2) and failing to monitor skin and wound conditions for one of nine residents reviewed (Resident 4).
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures.
Inspectors wroteBased on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that dependent residents were given proper nail care for one of nine residents reviewed (Resident 6).
Inspectors wroteBased on clinical record reviews, observations, and interviews with residents and staff, it was determined that the facility failed to provide foot care for one of nine residents reviewed (Resident 1).
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status, by failing to ensure timely notification of the physician for one of nine residents reviewed (Resident 4).
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained to flush long-term intravenous catheters (small tube inserted into a vein to deliver fluids or medication) for one of nine residents reviewed (Resident 4).
Inspectors wroteBased on clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide food consistency in accordance with each resident's needs for one of nine residents reviewed (Resident 5).
Inspectors wroteBased on review of clinical records and dietary records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were served food in accordance with their preferences and requests for one of nine residents reviewed (Resident 5).
13 fire safety citations on file: 3 on November 20, 2025, 2 on January 30, 2025, 8 on February 14, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| November 18, 2025 | Fine | $12,594 |
| June 4, 2024 | Fine | $46,982 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.25 | 3.89 | 3.86 |
| Registered nurses | 0.44 | 0.79 | 0.69 |
| All nursing staff on weekends | 2.99 | 3.53 | 3.42 |
| Nurse aides | 1.95 | ||
| Licensed practical nurses | 0.86 | ||
| Nursing staff turnover (share who left in a year) | 50.4% | 44.5% | 45.8% |
| Registered nurse turnover | 56.3% | 39.9% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.65 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.35 on weekdays and 2.99 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 15.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.48 in April to June 2025 to 3.25 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.25 | 0.44 | 3.35 | 2.99 | 15.0% | 0 of 90 | 169 |
| Oct to Dec 2025 | 3.23 | 0.47 | 3.36 | 2.92 | 8.2% | 0 of 92 | 162 |
| Jul to Sep 2025 | 3.36 | 0.48 | 3.51 | 2.97 | 10.4% | 0 of 92 | 154 |
| Apr to Jun 2025 | 3.48 | 0.45 | 3.63 | 3.10 | 12.0% | 0 of 91 | 155 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Pennsylvania, Jan to Mar 2026 | 3.69 | 0.65 | 3.82 | 3.34 | 11.3% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Pennsylvania, all employers | |||
| CNAs (nursing assistants) | $21.44 | $18.88 to $22.52 | 67,740 |
| LPNs and LVNs | $30.74 | $29.02 to $35.01 | 38,260 |
| Registered nurses | $46.36 | $38.75 to $50.35 | 146,520 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 17.6 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.4 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.4 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 4.1 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 21.0 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.9 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 20.8 | 17.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 30.2 | 22.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 6.8 | 9.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.2 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Maple Heights Health & Rehab Center, LLC's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (41.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
41.1% this home
No different from the national rate
US median of homes 51.5% · Pennsylvania: 100 better, 108 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 43 eligible stays.
12.3% this home
No different from the national rate
US median of homes 10.7% · Pennsylvania: 3 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 63 eligible stays.
7.5% this home
No different from the national rate
US median of homes 7.1% · Pennsylvania: 7 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 37 eligible stays.
39.1% this home
Median of homes: Pennsylvania54.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 64 residents counted.
3.1% this home
Median of homes: Pennsylvania0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 98 residents counted.
4.1% this home
Median of homes: Pennsylvania2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 98 residents counted.
100.0% this home
Median of homes: Pennsylvania100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 32 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: MAPLE HEIGHTS HEALTH & REHAB CENTER, LLC. CMS links this home to Saber Healthcare Group, a group of 126 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Volpe, Benjamin | Corporate director | Individual | 07/01/2023 | |
| Weisberg, William | Corporate director | Individual | 07/01/2023 | |
| Nicoluzakis, Gregory | Corporate officer | Individual | 07/01/2023 | |
| Volpe, Benjamin | Corporate officer | Individual | 07/01/2023 | |
| Weisberg, William | Corporate officer | Individual | 07/01/2023 | |
| Shg Management LLC | Operational/managerial control | Organization | 07/01/2023 | |
| Bobitski, Nicole | Operational/managerial control | Individual | 07/08/2024 | |
| Leonard, Richard | Operational/managerial control | Individual | 09/23/2024 | |
| Weisberg, William | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 10/06/2025 | |
| Benjamin N. Volpe Family Dynasty Trust (dated December 29, 2020) | Adp of the SNF | Organization | 07/01/2023 | |
| Bnv Dynasty LLC | Adp of the SNF | Organization | 07/01/2023 | |
| Citrin Cooperman Advisors LLC | Adp of the SNF | Organization | 07/01/2023 | |
| Decanted William I. Weisberg Family Dynasty Trust (dated Sept 30, 2020 | Adp of the SNF | Organization | 07/01/2023 | |
| Maple Heights Re Group, LLC | Adp of the SNF | Organization | 06/30/2023 | |
| Rkl LLP | Adp of the SNF | Organization | 07/01/2023 | |
| Saber Governance LLC | Adp of the SNF | Organization | 07/01/2023 | |
| Saber Healthcare Group LLC | Adp of the SNF | Organization | 07/01/2023 | |
| Shg Management LLC | Adp of the SNF | Organization | 07/01/2023 | |
| Western Pa Mt LLC | Adp of the SNF | Organization | 10/06/2025 | |
| Wiw Dynasty LLC | Adp of the SNF | Organization | 07/01/2023 | |
| Bobitski, Nicole | Adp of the SNF | Individual | 07/08/2024 | |
| Leonard, Richard | Adp of the SNF | Individual | 09/23/2024 | |
| Nicoluzakis, Gregory | Adp of the SNF | Individual | 07/01/2023 | |
| Ratchford, Donald | Adp of the SNF | Individual | 07/01/2023 | |
| Volpe, Benjamin | Adp of the SNF | Individual | 07/01/2023 | |
| Weisberg, William | Adp of the SNF | Individual | 07/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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