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Midtown Oaks Health & Rehab Center

1020 Green Avenue, Altoona, PA 16601 · Blair County · (814) 946-2700

120 certified beds, about 96 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1996

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 395985 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on July 15, 2026, inspectors cited 15 health deficiencies (the Pennsylvania average is 10, the national average 9.2).

Of 106 health citations since September 2023, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 2 fines totaling $99,042 in the last three years; the largest was $76,811, and the latest is dated August 22, 2024.

Nurses and nurse aides worked 3.52 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.67 of those hours.

57.4% 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.

Health inspections

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.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

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 106 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
66D
35E
3F
Potential for minimal harm
0A
0B
0C
July 15, 2026Standard inspection, Complaint inspection · 15 citations
  1. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 18, 2026
    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 (MDS) assessments for six of 45 residents reviewed (Residents 1, 5, 53, 66, 84 and 95).
  2. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 18, 2026
    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 four of 45 residents reviewed (Resident's 4, 53, 102, 116).
  3. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 18, 2026
    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 regarding medication administration were followed for three of 45 residents reviewed (Residents 10, 116 and 118).
  4. E
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on review of facility policies and clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement a comprehensive behavior management program for one of 45 residents reviewed (Resident 90).
  5. E
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was addressed timely by the physician for two of 45 residents reviewed (Residents 7 and 78), resulting in the residents receiving unnecessary anti-infective medications.
  6. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, in accordance with professional standards for food service safety. Finding Include: The facility's policy regarding storage of refrigerated foods, dated May 21, 2026, indicated that refrigerators in the facility used to store facility purchased food for residents should be equipped with an internal thermometer, even when equipped with an external thermometer. All perishable foods will be stored in order to maximize food safety and quality. Observations in the main kitchen on July 12, 2026, at 9:10 a.m. revealed a milk cooler containing four partial crates of milk that did not have an internal temperature gage. The walk in cooler had four containers of Dannon vanilla yogurt. [...]
  7. D
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    F557 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on a review of facility policies, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide care in a manner that maintained dignity for one of 45 residents reviewed (Resident 116).
  8. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 45 residents reviewed (Resident 105).
  9. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on review of clinical records, observations, shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 45 residents reviewed (Resident 36).
  10. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on a review of facility policies, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide the resident with requested bed pan resulting in bowel incontinence for one of 45 residents reviewed (Resident 116).
  11. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    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 45 residents reviewed (Residents 7 and 53).
  12. D
    Ensure 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on review of facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label medications in accordance with currently accepted professional principles by including the expiration date on liquid medication in one of two medication carts reviewed (3rd floor long hall).
  13. D
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    F806 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on clinical record reviews, observations and resident and staff interviews, it was determined that the facility failed to honor food preferences for one of 45 residents reviewed (Resident 116).
  14. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 45 residents reviewed (Resident 7).
  15. D
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on review of the facility's plans of correction 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.
February 27, 2026Standard inspection · 9 citations
  1. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased on review of polices and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 38 residents reviewed (Resident 42, 44 and 66).
  2. E
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 31, 2026
    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 followed for one of 38 residents reviewed (Resident 2) who had a feeding tube.
  3. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 31, 2026
    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 (drugs with the potential to be abused) for two of 38 residents reviewed (Resident 10, 113).
  4. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication administration for one of 38 residents reviewed (Resident 13), and during wound care for two of 38 residents reviewed (Residents 8, 69).
  5. E
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 31, 2026
    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 each resident was offered and/or received the pneumococcal immunization for four of 38 residents reviewed (Residents 2, 16, 36, 45).
  6. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased on clinical record reviews and resident and 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 38 residents reviewed (Resident 71).
  7. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act, [NAME] Medication Administration rights, facility policies, and observations, as well as staff interviews, it was determined that the facility failed to document medication administration at the time of administration for one of 38 residents reviewed (Resident 13).
  8. D
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    F694 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to follow physician's orders related to midline catheters (a type of peripheral catheter inserted into a large vein in the upper arm used to deliver fluids and/or medications) for 2 of 38 residents reviewed (Resident 3 and Resident 71).
  9. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased on review of policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 38 residents reviewed (Resident 13).
February 12, 2026Complaint inspection · 2 citations
  1. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were implemented for one of six residents reviewed (Resident 2) regarding nutritional interventions.
  2. E
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 31, 2026
    Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to initiate nutritional interventions to assure that residents were offered sufficient food and fluid intake to maintain proper hydration and health for one of six residents reviewed (Resident 2).
December 30, 2025Complaint inspection · 1 citation
  1. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 15, 2026
    Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain confidentiality of residents' personal health information for one of seven residents reviewed (Resident 4).
September 11, 2025Standard inspection, Complaint inspection · 8 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) October 14, 2025
    Inspectors wroteBased on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety in the kitchen, in one of two pantries (second floor) and one of two refrigerators (third floor pantry) observed.
  2. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 14, 2025
    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 four of 50 residents reviewed (Residents 3, 8, 45, 82).
  3. E
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 14, 2025
    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.
  4. D
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    F636 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2025
    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 four of 50 residents reviewed (Residents 35, 45, 89, 117).
  5. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2025
    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 care plan was updated/revised to reflect the resident's specific care needs for two of 50 residents reviewed (Residents 6 and 7).
  6. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2025
    Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for two of 50 residents reviewed (Residents 46, 53).
  7. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2025
    Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for one of 50 residents reviewed (Resident 7).
  8. D
    Ensure 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2025
    Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored for one of 50 residents reviewed (Resident 56).
August 6, 2025Complaint inspection · 5 citations
  1. E
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 26, 2025
    Inspectors wroteBased on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified when needed for two of 12 residents reviewed (Residents 1, 2).
  2. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 26, 2025
    Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for two of 12 residents reviewed (Residents 1, 2), and failed to follow recommendations from the orthopedist (a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system disorders) for a therapy evaluation for one of 12 residents reviewed (Resident 2).
  3. E
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 26, 2025
    Inspectors wroteBased on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 12 residents reviewed (Resident 2).
  4. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 26, 2025
    Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food items that were palatable.
  5. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 26, 2025
    Inspectors wroteBased on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who required urinary catheterization (a flexible tube inserted into the bladder to drain urine) was completed as ordered for one of 12 residents reviewed (Resident 2).
June 25, 2025Complaint inspection · 1 citation
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 10, 2025
    Inspectors wroteBased on review of facility policies, clinical records, and shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for four of nine residents reviewed (Residents 4, 5, 6, 7).
June 16, 2025Complaint inspection · 1 citation
  1. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 1, 2025
    Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food items that were palatable.
April 22, 2025Complaint inspection · 3 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 13, 2025
    Inspectors wroteBased on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to have staff wear appropriate hair restraints during food preparation and tray line service.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 13, 2025
    Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of five residents reviewed (Resident 2).
  3. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 13, 2025
    Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of five residents reviewed (Resident 2).
March 4, 2025Complaint inspection · 1 citation
  1. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 25, 2025
    Inspectors wroteBased on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene by failing to provide showers as scheduled for one of six residents reviewed (Resident 2).
January 28, 2025Complaint inspection · 3 citations
  1. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 14, 2025
    Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide timely treatment to a newly identified pressure ulcer for one of 10 residents reviewed (Resident 9).
  2. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 14, 2025
    Inspectors wroteBased on review of clinical records, as well staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 10 residents reviewed (Resident 10).
  3. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 14, 2025
    Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 10 residents reviewed (Resident 1).
December 23, 2024Complaint inspection · 2 citations
  1. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 23, 2025
    Inspectors wroteBased on review of facility polices and 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 two of eight residents reviewed (Residents 2, 5).
  2. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 23, 2025
    Inspectors wroteBased on review of facility investigation documents and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans for one of eight residents reviewed (Resident 1) resulting in a fall.
August 22, 2024Complaint inspection · 15 citations
  1. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2024
    Inspectors wroteBased on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow a physician's recommendations for one of 45 residents reviewed (Residents 13) resulting in a deterioration of the wound with increased size, and there was no documented evidence that physician's orders were followed for two of 45 residents reviewed (Residents 12, 86).
  2. F
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on review of policies, as well as observations and interviews with residents and staff, it was determined that hot foods were not served at proper and palatable temperatures.
  3. E
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    F553 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    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 resident and/or the resident's responsible party was given the opportunity to participate timely in the development and implementation of a person-centered care plan for two of 45 residents reviewed (Residents 12, 77).
  4. E
    Assist a resident in gaining access to vision and hearing services.
    F685 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders and residents' requests for ophthalmology appointments for two of 45 residents reviewed (Residents 69, 87).
  5. E
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on review of policy and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for two of 45 residents reviewed (Residents 30, 89).
  6. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2024
    Inspectors wroteBased on review of facility policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that a resident's call bell was within reach for one of 45 residents reviewed (Resident 19).
  7. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for two of 45 residents reviewed (Residents 12, 30).
  8. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on a review of clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 45 residents reviewed (Resident 12).
  9. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for two of 45 residents reviewed (Residents 13, 51) who used an air mattress.
  10. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2024
    Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to address a change in urine status for one of 45 residents (Resident 12), and failed to provide proper care for indwelling urinary catheters for one of 45 residents reviewed (Resident 67).
  11. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to provide aggressive hydration of 4 liters a day recommended by urology for one of 45 residents reviewed (Resident 12).
  12. D
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide and document care as scheduled for two of 45 residents reviewed (Residents 12, 19).
  13. D
    Ensure 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2024
    Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that controlled medications were stored in a separately locked, permanently affixed compartment in one of two medication rooms reviewed (second floor), and failed to date an insulin pen with the date it was opened (third floor long hall medication cart).
  14. D
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    F810 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2024
    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 provided assistive devices to eat in accordance with the resident's care plan for two of 45 residents reviewed (Residents 12, 28).
  15. D
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2024
    Inspectors wroteBased on review of facility policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the call bell system was working for one of 45 resident reviewed (Resident 34).
July 3, 2024Complaint inspection · 16 citations
  1. K
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · Immediate jeopardy to resident health or safety, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on review of policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the call bell system was working. This failure put 15 of 22 residents reviewed who need to utilize their call bell for staff assistance in an Immediate Jeopardy situation.
  2. E
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on review of facility policy, clinical records, and Resident Council meeting minutes, as well as observations and resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve resident grievances presented during the resident council meetings and for one of 22 residents reviewed (Resident 17).
  3. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on a review of clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 22 residents reviewed (Resident 16).
  4. E
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for two of 22 residents reviewed (Residents 1, 16).
  5. E
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on review of the facility's written menus, observations, and staff interviews, it was determined that the facility failed to follow their planned menu for three of 22 residents reviewed (Residents 17, 18, 20).
  6. E
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    F808 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on a review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the physician for one of 22 residents reviewed (Resident 19).
  7. E
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 22 residents reviewed (Resident 2).
  8. D
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    F557 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to treat residents with dignity by failing to answer call bells timely for one of 22 residents reviewed (Resident 17).
  9. D
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms on one of two halls toured (200 hall).
  10. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian, in writing, regarding the reason for hospitalization for one of 22 residents reviewed (Resident 2).
  11. D
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed issue a bed hold notice at the time of an anticipated leave of absence from the facility for one of 22 residents reviewed (Resident 2).
  12. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 22 residents reviewed (Resident 8), and failed to clarify physician's orders for one of 22 residents reviewed (Resident 12).
  13. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to follow physician's orders for three of 22 residents reviewed (Residents 2, 3, 12).
  14. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to ensure oxygen concentrators were functioning properly for four of 22 residents reviewed (Residents 13, 14, 15, 16).
  15. D
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    F810 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    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 provided assistive devices to eat in accordance with the resident's care plan for one of 22 residents reviewed (Resident 17).
  16. D
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    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 facility was adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area from their rooms or bathrooms.
June 18, 2024Complaint inspection · 1 citation
  1. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 1, 2024
    Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect for one of seven residents reviewed (Resident 7).
April 18, 2024Complaint inspection · 6 citations
  1. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 16, 2024
    Inspectors wroteBased on review of clinical records and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained safe for two of nine residents reviewed (Residents 2, 4) and failed to conduct a thorough investigation of resident-to-resident altercations to determine if care-planned interventions were followed for one of nine residents reviewed (Resident 6).
  2. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 16, 2024
    Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to accommodate residents' preferences regarding showers for two of nine residents reviewed (Residents 5, 8).
  3. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 16, 2024
    Inspectors wroteBased on review of facility polices and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop a plan of care to address a resident's psychosocial well-being related to her fear and not feeling safe after a resident-to-resident incident for one of nine residents reviewed (Resident 7).
  4. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 16, 2024
    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 care plan was updated/revised to reflect the resident's specific behavioral intervention for one of nine residents reviewed (Resident 4).
  5. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    F742 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 16, 2024
    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 nine residents reviewed (Resident 2).
  6. D
    Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
    F743 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 16, 2024
    Inspectors wroteBased on clinical record reviews and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that a resident did not display increased angry and aggressive behaviors by not following care-planned interventions for one of nine residents reviewed (Resident 6), resulting in the resident hitting another resident, and failed to evaluate appropriate treatment and services to maintain the resident's highest practicable physical and mental well-being by failing to address a resident's fear and not feeling safe after a resident-to-resident incident for one of nine residents reviewed (Resident 7).
March 20, 2024Complaint inspection · 1 citation
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 11, 2024
    Inspectors wroteBased on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and transfer status for one of 10 residents reviewed (Resident 1).
January 5, 2024Complaint inspection · 5 citations
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 2, 2024
    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 staff reported allegations of sexual abuse by one resident (Resident 7) towards two residents (Residents 8, 9) in a timely manner.
  2. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 2, 2024
    Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation into incidents involving inappropriate sexual behavior of one resident (Resident 7) towards two other residents (Residents 8, 9).
  3. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 2, 2024
    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 residents were provided with showers as scheduled for one of seven residents reviewed (Resident 6).
  4. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 2, 2024
    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 for medications were followed for one of seven residents reviewed (Resident 3).
  5. D
    Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
    F772 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 2, 2024
    Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to obtain blood work as ordered by the physician for one of seven residents reviewed (Resident 4).
November 15, 2023Complaint inspection · 8 citations
  1. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for two of 13 residents reviewed (Residents 2, 7).
  2. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for one of 13 residents reviewed (Resident 8).
  3. E
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 13 residents reviewed (Resident 3).
  4. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on review of policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at proper temperatures.
  5. D
    Honor each resident's preferences, choices, values and beliefs.
    F675 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriately while eating for one of 13 residents reviewed (Resident 10).
  6. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a safe environment was provided for one of 13 residents reviewed (Resident 1).
  7. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on a review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to provide timely incontinence care for one of 13 residents reviewed (Resident 10).
  8. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2023
    Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the residents were free from unnecessary medications for one of 13 residents reviewed (Resident 11).
September 8, 2023Complaint inspection · 3 citations
  1. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 6, 2023
    Inspectors wroteBased on review of policies 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 three of 41 residents reviewed (Residents 6, 65, 76).
  2. D
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 6, 2023
    Inspectors wroteBased on review of clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding mechanical lifts.
  3. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 6, 2023
    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 each resident was assessed, offered and/or received the pneumococcal immunizations for two of 41 residents reviewed (Residents 8, 11).

Fire safety inspections

2 fire safety citations on file: 2 on September 11, 2025.

Every fire safety citation2 citations
  1. D
    Have power receptacles that are properly grounded.
    K 912 · September 11, 2025 · Corrected (the home has a date of correction)
  2. D
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · September 11, 2025 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
August 22, 2024Fine $76,811
June 18, 2024Fine $22,231

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homePennsylvaniaUnited States
All nursing staff (RN, LPN and aides)3.523.893.86
Registered nurses0.670.790.69
All nursing staff on weekends3.263.533.42
Nurse aides2.00
Licensed practical nurses0.85
Nursing staff turnover (share who left in a year)57.4%44.5%45.8%
Registered nurse turnover52.4%39.9%42.9%
Administrators who left1

CMS expects 4.13 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

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 3.63 on weekdays and 3.26 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.41 in April to June 2025 to 3.52 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.520.673.633.26 0.7%0 of 9096
Oct to Dec 20253.460.713.573.20 1.2%0 of 9291
Jul to Sep 20253.520.723.683.10 6.4%0 of 9295
Apr to Jun 20253.410.663.483.23 9.9%0 of 9195
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Pennsylvania, Jan to Mar 20263.690.653.823.3411.3%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

Staff pay at this home

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.

Official wage estimates for Pennsylvania

JobMedianMiddle halfEmployed
Pennsylvania, all employers
CNAs (nursing assistants)$21.44$18.88 to $22.5267,740
LPNs and LVNs$30.74$29.02 to $35.0138,260
Registered nurses$46.36$38.75 to $50.35146,520
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

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.

Work here? Share your pay anonymously

For Midtown Oaks Health & Rehab Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
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Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

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Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homePennsylvaniaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
22.916.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.70.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.31.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
4.33.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.51.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
20.917.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
7.24.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
15.817.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
28.522.523.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
9.79.512.0

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Midtown Oaks Health & Rehab Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (31.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

31.1% this home

Worse than 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. 48 eligible stays.

Potentially preventable readmissions

11.3% 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. 49 eligible stays.

Infections that led to a hospital stay

6.4% 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. 36 eligible stays.

Self-care and mobility at discharge

39.5% 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. 38 residents counted.

Falls with major injury

0.0% 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. 45 residents counted.

New or worsened pressure ulcers

0.0% 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. 45 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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. 16 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.

Owners and operators

Legal business name: MIDTOWN OAKS HEALTH & REHAB CENTER, LLC. CMS links this home to Saber Healthcare Group, a group of 126 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Volpe, BenjaminCorporate directorIndividual07/01/2023
Weisberg, WilliamCorporate directorIndividual07/01/2023
Nicoluzakis, GregoryCorporate officerIndividual07/01/2023
Volpe, BenjaminCorporate officerIndividual07/01/2023
Weisberg, WilliamCorporate officerIndividual07/01/2023
Shg Management LLCOperational/managerial controlOrganization07/01/2023
Bobitski, NicoleOperational/managerial controlIndividual07/08/2024
Folckemer, JessicaOperational/managerial controlIndividual04/29/2025
Weisberg, WilliamIndividual is an owner, partner or trustee of any ADP of the SNFIndividual10/03/2025
Benjamin N. Volpe Family Dynasty Trust (dated December 29, 2020)Adp of the SNFOrganization07/01/2023
Bnv Dynasty LLCAdp of the SNFOrganization07/01/2023
Citrin Cooperman Advisors LLCAdp of the SNFOrganization07/01/2023
Decanted William I. Weisberg Family Dynasty Trust (dated Sept 30, 2020Adp of the SNFOrganization07/01/2023
Midtown Oaks Re Group, LLCAdp of the SNFOrganization06/30/2023
Rkl LLPAdp of the SNFOrganization07/01/2023
Saber Governance LLCAdp of the SNFOrganization07/01/2023
Saber Healthcare Group LLCAdp of the SNFOrganization07/01/2023
Shg Management LLCAdp of the SNFOrganization07/01/2023
Western Pa Mt LLCAdp of the SNFOrganization10/06/2025
Bobitski, NicoleAdp of the SNFIndividual07/08/2024
Folckemer, JessicaAdp of the SNFIndividual04/29/2025
Nicoluzakis, GregoryAdp of the SNFIndividual07/01/2023
Scharf, BrettAdp of the SNFIndividual08/01/2024
Volpe, BenjaminAdp of the SNFIndividual07/01/2023
Weisberg, WilliamAdp of the SNFIndividual07/01/2023

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.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 37 problems in this area, most recently on July 15, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. When is the care plan meeting, and can family attend it?Inspectors cited 17 problems in this area, most recently on July 15, 2026: "Ensure each resident receives an accurate assessment."
  3. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 14 problems in this area, most recently on July 15, 2026: "Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 12 problems in this area, most recently on July 15, 2026: "Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.26 hours per resident per day, below the Pennsylvania average of 3.53.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

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Pennsylvania contacts for a concern about a nursing home

These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.

Common questions

What is Midtown Oaks Health & Rehab Center's Medicare star rating?
CMS rates Midtown Oaks Health & Rehab Center 1 out of 5 stars overall, with 1 for health inspections, 2 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Midtown Oaks Health & Rehab Center get at its last inspection?
15 health deficiencies at the standard inspection on July 15, 2026. The Pennsylvania average is 10.
Has Midtown Oaks Health & Rehab Center been fined?
Yes. CMS lists 2 fines totaling $99,042 in the last three years.
Does Midtown Oaks Health & Rehab Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Midtown Oaks Health & Rehab Center?
CMS lists 25 owners and managers, and links the home to Saber Healthcare Group. Legal business name: MIDTOWN OAKS HEALTH & REHAB CENTER, LLC.

Sources

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