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Providence Health & Rehab Center

900 Third Ave, Beaver Falls, PA 15010 · Beaver County · (724) 846-8504

180 certified beds, about 167 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1984

Special Focus Facility candidate CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 395682 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on August 7, 2026, inspectors cited 30 health deficiencies (the Pennsylvania average is 10, the national average 9.2).

Of 107 health citations since January 2024, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 11 fines totaling $56,804 in the last three years; the largest was $14,385, and the latest is dated May 21, 2026.

Nurses and nurse aides worked 3.27 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.72 of those hours.

41.7% 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 107 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
68D
32E
4F
Potential for minimal harm
0A
0B
0C
August 7, 2026Standard inspection · 30 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 · Not yet corrected
    Inspectors wroteBased on review of policy, observation and staff interview, it was determined that the facility failed to properly label and date food products, creating the potential for food-borne illness in the main kitchen's standing cooler rack and dry storage area.
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Not yet corrected
    Inspectors wroteBased on facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for three of four residents (Resident R26, R178, and R179) and failed to provide the right to a dignified dining experience for one of two lunches observed (2B Nurse unit Lunch).
  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 · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for three of three residents (Resident R26, R39, and R91).
  4. E
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R4, R10, and R72), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of five resident hospital transfers (Residents R4 and R10), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of five resident hospital transfers (Residents R4, R10, and R72).
  5. 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 · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for four of six residents (Residents R2, R14, R135, and R155).
  6. E
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    F700 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of five residents (Residents R2, R14, and R160).
  7. E
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Not yet corrected
    Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide (NA) personnel records (NA Employee E23, NA Employee E24, and NA Employee E25).
  8. 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 · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence medication regimen reviews (MRRs) were reviewed by the resident's attending physician monthly for three of five residents (Residents R2, R4 and R7).
  9. E
    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, pattern · Not yet corrected
    Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in four of five medications carts (2C2 Medication Cart, 2A Medication Cart, 2B Medication Cart, and 1B Medication Cart) and one of six resident rooms (Resident R74).
  10. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Not yet corrected
    Inspectors wroteBased on review of facility policy, resident records, a facility tour, observations, and staff interview it was determined that the facility failed to utilize proper food handling procedures during the lunch meal creating the potential for cross contamination for one out of five residents (Residents R97), failed to prevent cross contamination during a medication administration for one of five med pass observations (2B Med Pass), failed to follow proper use of personal protective equipment (PPE) for one of four residents (Resident R91), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for eight of twelve months (September 2025, through April 2026).
  11. E
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Not yet corrected
    Inspectors wroteBased on review of the facility policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for eight of 12 months (September 2025, through April 2026).
  12. 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 · Not yet corrected
    Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for three of five residents (Resident R4, R26, and R72).
  13. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of facility policy and documents, resident and staff interviews, it was determined that the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences for enabler bars for one of five residents (Resident R105).
  14. D
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    F565 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of facility policy, resident family interviews and documentation, and staff interviews it was determined that the facility failed to assist a resident family with forming a family group for three of three resident families (Resident Family Representatives FR116, FR121, and Resident Family Representative FR300).
  15. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on resident clinical records, facility documents, and staff interview it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for one of three sampled resident records (Resident R120).
  16. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (2B Medication Cart).
  17. 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 · Not yet corrected
    Inspectors wroteBased on observations and staff interview it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (Second floor).
  18. D
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    F604 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint and failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for two of four residents (Residents R2 and R87).
  19. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of facility policy, personnel records and staff interview, it was determined that the facility failed to conduct an FBI background check on agency personnel prior to working on the nursing unit for one out of six personnel records (Agency Nurse aide (NA) Employee E20).
  20. 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 · Not yet corrected
    Inspectors wroteBased on review of facility policy, resident records, resident council minutes, facility investigation documents, incidents submitted to the local State field office, resident interview, and staff interviews it was determined that the facility failed to submit a report of an allegation of verbal abuse for one of four sampled resident records (Resident R9).
  21. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for one of three residents (Resident R164).
  22. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the resident for one of three residents reviewed (Resident R181).
  23. 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 · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers/injuries (PU/PI's - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four residents (Resident R8 and R181).
  24. D
    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, isolated · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Resident R181).
  25. 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 · Not yet corrected
    Inspectors wroteBased on review of facility policy, clinical records, staff interviews, and resident observations it was determined that the facility failed to include care and management of a PICC line (peripherally inserted central catheter - a long thin flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart) consistent with professional standards of practice for one of two residents (Resident R181).
  26. 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 · Not yet corrected
    Inspectors wroteBased on observation, review of clinical record, review of facility policy, interview with staff and resident, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of three residents receiving oxygen (Resident R80) and failed to provide tracheostomy care consistent with professional standards of practice for one of three residents (Resident R164).
  27. D
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    F838 · Administration · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to accurately complete the Facility Assessment.
  28. 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 · Not yet corrected
    Inspectors wroteBased on review of facility documentation, results of previous survey, and results of the current survey, it was determined that the facility 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 deficiencies.
  29. D
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (a cart that contains supplies in the event of an emergency) for two of six nursing units (Nursing units 1B and 2B).
  30. D
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    F944 · Administration · No actual harm, potential for more than minimal harm, isolated · Not yet corrected
    Inspectors wroteBased on review of facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for one of five staff members (Registered Nurse (RN) Employee E22).
July 9, 2026Complaint inspection · 3 citations
  1. 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 · found on a complaint visit · Not yet corrected
    Inspectors wroteBased on a review of closed clinical record review and staff interviews, it was determined that the facility failed to involve the resident's representative in the treatment decision and communicate treatment decision involving testing for one of three sampled residents (Closed Resident Record CR1).
  2. 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 · Not yet corrected
    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 and revised to reflect the resident's specific care needs for one of three sampled resident records (Closed Resident Record CR1).
  3. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Not yet corrected
    Inspectors wroteBased on review of facility policy, closed resident clinical records and staff interviews, it was determined that the facility failed to complete a comprehensive activity assessment to ascertain resident's activity interest and preferences for one of three closed resident records (Closed Resident Record CR2).
May 21, 2026Complaint inspection · 4 citations
  1. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 9, 2026
    Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility. This failure created an immediate jeopardy situation (IJ) for all residents identified as an elopement risk.
  2. F
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    F850 · Administration · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) June 9, 2026
    Inspectors wroteBased on review of facility files and staff interview, it was determined that the facility failed to employ a full-time qualified social worker from February 16, 2026, through present.
  3. 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) June 9, 2026
    Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop person-centered comprehensive care plans to meet resident care needs for three of three residents identified as an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) risk (Residents R2, R3, and R4).
  4. 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) June 9, 2026
    Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility on 5/10/26, which created an immediate jeopardy situation for all residents identified as an elopement risk.
February 20, 2026Complaint inspection · 2 citations
  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 · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on review of facility policy, facility documentation, resident records, resident interview and staff interviews, it was determined that the facility neglected to provide goods and services for one out of five sampled records (Resident R1). The deficiency is cited as past non-compliance.
  2. 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) March 10, 2026
    Inspectors wroteBased on review of facility policy, resident clinical records, facility documentation, resident interview, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of five sampled residents (Resident R1).
January 6, 2026Complaint 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) January 27, 2026
    Inspectors wroteBased on review of the facility's admission notice packet, observations, and staff interview, it was determined that the facility failed to accommodate the shower needs for one of five residents (Resident R1).
  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) January 27, 2026
    Inspectors wroteBased on review of facility policy, clinical record, observations, and interviews with staff and residents, the facility failed to provide appropriate care and treatment post fall for one of three residents (Closed Record Resident CR1).
  3. D
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    F688 · 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 27, 2026
    Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents (Residents R2).
August 22, 2025Standard inspection · 21 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 · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for six of 34 residents (Resident R3, Resident R8, Resident R55, Resident R63, Resident R148, and Resident R151).
  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 · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of abnormal Capillary Blood Glucose (CBG) readings as per physician's order for one of three sampled residents (Residents R148) and failed to provide comprehensive skin assessments and provide appropriate care and treatment for two of five residents (Resident R31 and Residents R38) reviewed with skin condition concerns and failed to follow physician orders for vitals for one of five resident (Resident R2).
  3. 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 · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to identify and assess a resident for smoking safety in a timely manner for two of two residents (Residents R79 and R98), failed to reassess a resident after an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge), and failed to develop a comprehensive care plan with interventions to address the potential for elopement for one of three residents (Resident R110).
  4. E
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    F700 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of three residents (Residents R4, R54, and R95).
  5. E
    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, pattern · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of three medications rooms (2A, ), and one of four medication carts (3A Medication Cart).
  6. 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) October 7, 2025
    Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent potential of cross contamination in one of three medication refrigerators (2B medication refrigerator), failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R82), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of 11 months (September 2024, October 2024, November 2024, and December 2024).
  7. 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) October 7, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that an influenza immunization was offered to one of five residents (Resident R33), and failed to make certain that a pneumococcal immunization was offered to two of five residents (Residents R5 and R118).
  8. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Resident R82).
  9. D
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    F565 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of resident and staff interview it was determined that the facility failed to respond to resident concerns and grievances identified during resident council meeting.
  10. D
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    F604 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policies and clinical records, observations and staff interviews it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for one of four residents (Resident R76).
  11. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for two of three residents (Resident R8 and Resident R63).
  12. 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 · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for two of three residents (Resident R2 and Resident R33).
  13. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policy, facility documents, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for allegations of neglect for two of three residents (Residents R2 and Resident R33).
  14. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of two residents sampled with facility-initiated transfers (Residents R4 and R114), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of two resident hospital transfers (Residents R4, and R114).
  15. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of five residents (Residents R79 and R95).
  16. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on observations, staff interviews, and review of facility activities calendars, it was determined that the facility failed to provide sufficient activities to meet their interests and support the physical, mental, and psychosocial well-being of each resident on two out of five days observed on the Third Floor Memory Impaired unit (8/18/25 and 8/19/25). Based on facility policy, observations, review of facility activities calendars, and staff interviews, it was determined that the facility failed to provide sufficient activities to meet the interests of resident on two out five days observed on the Third Floor Memory impaired unit (8/18/25 and 8/19/25).
  17. 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 · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to individualize care plans to address the resident specific nutritional concerns for two of six residents (Resident R10, and R76) and, failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Residents R10).
  18. D
    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, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of two residents (Resident R110), and failed to develop a comprehensive person-centered care plan to address resident needs for one of two residents (Resident R110).
  19. 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) October 7, 2025
    Inspectors wroteBased on review of facility policy and clinical records, family and staff interviews it was determined that the facility failed to make certain that residents are free of significant medication errors for two of two residents (Resident R2 and Resident R33).
  20. D
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of three residents (Resident R10, and R95).
  21. D
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 7, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for two of five residents (Residents R5 and R33).
June 18, 2025Complaint inspection · 3 citations
  1. E
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 31, 2025
    Inspectors wroteBased on review of facility policy, facility documentation, clinical record review, and staff interview it was determined that the facility failed to ensure that residents are free from misappropriation of resident property for 15 of 15 resident (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16).
  2. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · 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) July 31, 2025
    Inspectors wroteBased on review of facility documentation, the facility failed to train an employee in abuse for one of three employees (LPN Employee E1).
  3. 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) July 31, 2025
    Inspectors wroteBased on review of facility documentation, and staff interview it was determined that the facility failed to report an allegation of misappropriation.
May 16, 2025Complaint inspection · 2 citations
  1. 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) June 5, 2025
    Inspectors wroteBased on review of facility policy, and facility documents and staff interviews it was determined that the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for ten of 13 grievances in March 2025.
  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) June 5, 2025
    Inspectors wroteBased on review of facility policy, record review, and resident and staff interviews, and observations it was determined that the facility failed to provide a resident environment free of potential accidental hazards for two of six hallways (2A and 2B).
September 25, 2024Complaint inspection · 1 citation
  1. D
    Have a plan that describes the process for conducting QAPI and QAA activities.
    F865 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to implement a QAPI for staffing for LPN's.
September 13, 2024Standard inspection, Complaint inspection · 20 citations
  1. E
    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, pattern · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility policies, job descriptions, documents, clinical records, and staff interviews, it was determined that the facility failed to protect residents from verbal abuse and mental anguish for one of five residents reviewed (Resident CR2), and failed to provide necessary services of medication administration for 29 of 29 residents on the Memory Impaired Unit (Residents R16, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121.
  2. E
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate alleged allegation of abuse/neglect for 30 of 30 residents (Residents R16, R20, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121).
  3. E
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of six residents sampled with facility-initiated transfers (Residents R7, R9, R21, R56 and R58).
  4. E
    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, pattern · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of six residents (Residents R7, R9, R21, R56, and R58).
  5. E
    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, pattern · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of six resident hospital transfers (Resident R7, R9, R21, R56, and R58). Findings Include: Review of facility policy Resident Discharge-Transfer Letter Policy dated 6/1/24, indicated the resident or responsible party will receive a bed hold notice along with the discharge-transfer letter. Bed hold notices can be found in the electronic records. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. [...]
  6. 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) October 14, 2024
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for four of eighteen residents (Residents R63, R66, R98, and R111) to accurately reflect the current status of the resident and care needs.
  7. 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 · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide necessary supervision and monitoring of potential resident accidents for 29 of 29 residents on the Memory Impaired Unit (Residents R16, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121), and failed to assess and implement interventions to prevent the potential for elopement for one of two resident (Resident R233) reviewed.
  8. E
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    F868 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarterly meetings (October 2023, February 2024, and April 2024).
  9. 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) October 14, 2024
    Inspectors wroteBased on facility policies, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of two residents (Resident R12), failed to track Enhanced Barrier Precaution (EBP, a type of precautions used to take care of residents) for four of four residents (R53, R64, R81, and R109), failed to follow proper use of personal protective equipment (PPE) for one of three units (Unit one), failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for ten of ten months (November 2023 - August 2024), and failed to ensure that a comprehensive resident care plan was developed related to infection precautions for 5 of 5 residents (R2, R56, R58, R64, and R81).
  10. D
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    F569 · 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 14, 2024
    Inspectors wroteBased on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds in accordance with State law and closed accounts upon death in a timely manner for one of four closed resident records (Closed Resident Records CR1).
  11. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify a medical provider of a change in condition for one out of four residents (Resident R111).
  12. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R14).
  13. D
    Ensure each resident receives an accurate assessment.
    F641 · 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, 2024
    Inspectors wroteBased on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for two of twelve residents (Residents R52, and R111).
  14. 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 · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to notify a physician of abnormal glucose readings as per physician's order for one out of three sampled residents (Resident R21), and failed to make certain that residents were provided appropriate treatment and service for non-pressure wound dressing orders for one of twelve residents (Resident R66).
  15. 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 · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status and failed to ensure that a comprehensive resident care plan was developed related to pressure wounds for one of four residents (Residents R2).
  16. 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) October 14, 2024
    Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to ensure that appropriate treatment and services were provided for two of three residents with an indwelling urinary catheter (Residents R49 and R107).
  17. 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 · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for three of four residents (Residents R52, R60, and R101).
  18. 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 · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on observations, clinical record review, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 29 of 29 residents on the Memory Impaired Unit (Residents R16, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121). Findings Include: Review of the facility policy Dayforce Scheduling Policy dated 6/1/24, indicated Administrators, department leaders and all staff members are to be proficient in the use of Dayforce and use all its scheduling capabilities to ensure adequate staffing levels are maintained. [...]
  19. 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, 2024
    Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed (Cart 2A and 2C).
  20. D
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 14, 2024
    Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for ten of ten months (November 2023 through August 2024).
June 25, 2024Complaint inspection · 1 citation
  1. 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 · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). This was identified as past non-compliance.
May 29, 2024Complaint inspection · 7 citations
  1. F
    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, widespread · found on a complaint visit · Corrected (the home has a date of correction) July 9, 2024
    Inspectors wroteBased on a review of facility Resident Council Minutes and staff interviews, it was determined that the facility failed to provide adequate staffing for the number and acuity of the residents for five of seven months (11/23, 12/23, 2/24, 4/24, and 5/24) and failed to meet the potential needs of all residents.
  2. 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) July 9, 2024
    Inspectors wroteBased on a review of facility policies, observations and staff interviews, it was determined that the facility failed to make certain that two of two Food and Nutrition Staff members with facial hair properly restrain facial hair in the Main Kitchen. (Main Kitchen)
  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 · found on a complaint visit · Corrected (the home has a date of correction) July 9, 2024
    Inspectors wroteDuring a review of facility documents and staff interviews it was determined that the facility failed to develop and implement a policy and procedure for dispensing medication to residents who were leaving the facility on an extended Leave of Absence (LOA) and a method to monitor and reconcile the administration of narcotics for two of three alleged misappropriation of two resident's property (Resident R2 and Resident R6)
  4. E
    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, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 9, 2024
    Inspectors wroteBased on a review of facility four week cycle menu, Resident Council Minutes, and Staff interviews, it was determined that the facility failed to provide alternative menu selections of equal or greater nutrient value and appeal to the residents for the lunch and dinner meals for the four week cycle menu. (Four Week Cycle Menu)
  5. 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) July 9, 2024
    Inspectors wroteBased on a review of facility policies, facility documents and staff interviews it was determined that the facility failed to timely report an alleged incident and properly investigate allegations of misappropriation of resident property which failed to prevent reoccurrence of similar events for one of three incidents. (Resident R2)
  6. D
    Ensure each resident receives an accurate assessment.
    F641 · 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) July 9, 2024
    Inspectors wroteBased on a review of facility policies, documents, observations, and staff interviews, it was determined that the facility failed to accurately document resident activities of daily living (ADL) for one of three residents. (Resident R6).
  7. 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) July 9, 2024
    Inspectors wroteBased on observations, review of resident medical records and staff interviews it was determined that the facility failed to properly transfer one of three residents. (Resident R6)
April 25, 2024Complaint inspection · 2 citations
  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 · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on review of facility policy, clinical records, facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that a resident was free of neglect during transportation in a wheelchair for one out two sampled residents (Resident R5). This deficiency is cited as past non-compliance.
  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) May 22, 2024
    Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to ensure that residents received neurological assessments after an incident involving an unwitnessed fall for two of four sampled residents (Residents R1 and Resident R2).
March 21, 2024Complaint inspection · 2 citations
  1. G
    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 · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of the distal right tibia (fracture of the shin bone near the ankle). This deficiency is cited as past non-compliance.
  2. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on review of facility policy, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm when the resident received a fracture of the distal right tibia, one of two residents reviewed (Resident R1). This deficiency is cited as past non-compliance.
February 6, 2024Complaint inspection · 1 citation
  1. D
    Provide and implement an infection prevention and control program.
    F880 · 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) February 20, 2024
    Inspectors wroteBased on facility documents, observations, and staff interview, it was determined that the facility failed to have appropriate personal protective equipment (PPE) to prevent cross-contamination for one of four residents with respiratory infection.
January 18, 2024Complaint inspection · 5 citations
  1. 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) February 14, 2024
    Inspectors wroteBased on review of facility policy, clinical records, observation and interviews with staff, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers/wounds from developing or worsening for three of six residents (Residents R2, R3, and R4).
  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) February 14, 2024
    Inspectors wroteBased on review of facility policy, observations, resident council group meeting, resident and staff interview it was determined that the facility failed to answer call bells in a timely manner for one of four residents observed on the first floor nursing unit (Residents R1).
  3. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · 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 14, 2024
    Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of three incidents reviewed (Resident R2).
  4. 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 14, 2024
    Inspectors wroteBased on review of facility policy, clinical records, facility incident documents, resident, and staff interviews, it was determined that the facility failed to report an allegation of abuse within two hours for one of three residents (Resident R2).
  5. 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 14, 2024
    Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate an allegation of abuse for one of three residents (Resident R2).

Fire safety inspections

14 fire safety citations on file: 5 on August 7, 2026, 7 on August 22, 2025, 2 on September 13, 2024.

Every fire safety citation14 citations
  1. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · August 7, 2026 · deficient, provider has
  2. E
    Have simulated fire drills held at unexpected times.
    K 712 · August 7, 2026 · deficient, provider has
  3. D
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · August 7, 2026 · deficient, provider has
  4. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · August 7, 2026 · deficient, provider has
  5. D
    Have proper medical gas storage and administration areas.
    K 923 · August 7, 2026 · deficient, provider has
  6. E
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · August 22, 2025 · Corrected (the home has a date of correction)
  7. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · August 22, 2025 · Corrected (the home has a date of correction)
  8. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · August 22, 2025 · Corrected (the home has a date of correction)
  9. E
    Have power receptacles that are properly grounded.
    K 912 · August 22, 2025 · Corrected (the home has a date of correction)
  10. E
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · August 22, 2025 · Corrected (the home has a date of correction)
  11. C
    Conduct risk assessment and an All-Hazards approach.
    E 6 · August 22, 2025 · Corrected (the home has a date of correction)
  12. C
    Conduct testing and exercise requirements.
    E 39 · August 22, 2025 · Corrected (the home has a date of correction)
  13. E
    Install corridor and hallway doors that block smoke.
    K 363 · September 13, 2024 · Corrected (the home has a date of correction)
  14. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · September 13, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
May 21, 2026Fine $14,385
March 21, 2024Fine $8,400
March 21, 2024Fine $8,401
November 20, 2023Fine $4,634
November 13, 2023Fine $4,286
November 6, 2023Fine $3,937
October 30, 2023Fine $3,587
October 17, 2023Fine $2,823
October 10, 2023Fine $2,470
October 2, 2023Fine $2,117
September 25, 2023Fine $1,764

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)3.273.893.86
Registered nurses0.720.790.69
All nursing staff on weekends3.023.533.42
Nurse aides1.97
Licensed practical nurses0.58
Nursing staff turnover (share who left in a year)41.7%44.5%45.8%
Registered nurse turnover56.7%39.9%42.9%
Administrators who left1

CMS expects 3.79 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 3.38 on weekdays and 3.02 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 13.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.44 in April to June 2025 to 3.27 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.270.723.383.02 13.4%0 of 90167
Oct to Dec 20253.460.773.583.13 12.9%0 of 92157
Jul to Sep 20253.440.723.583.07 14.5%0 of 92150
Apr to Jun 20253.440.733.583.06 8.7%0 of 91147
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.

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.

How staff pay reports work · CNA pay by state

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
16.716.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.90.70.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.61.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
6.73.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
2.01.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
12.817.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
9.44.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
25.017.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
27.422.523.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
6.79.512.0

Owners and operators

Legal business name: PROVIDENCE 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
Parsons, ThomasOperational/managerial controlIndividual10/21/2024
Weisberg, WilliamIndividual is an owner, partner or trustee of any ADP of the SNFIndividual10/06/2025
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
Providence 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
Wiw Dynasty LLCAdp of the SNFOrganization07/01/2023
Bobitski, NicoleAdp of the SNFIndividual07/08/2024
Gehrlein, ChrisAdp of the SNFIndividual06/01/2024
Nicoluzakis, GregoryAdp of the SNFIndividual07/01/2023
Parsons, ThomasAdp of the SNFIndividual10/21/2024
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 27 problems in this area, most recently on August 7, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 21 problems in this area, most recently on August 7, 2026: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 19 problems in this area, most recently on August 7, 2026: "Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment."
  4. What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 9 problems in this area, most recently on August 7, 2026: "Provide and implement an infection prevention and control program."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.02 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

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 Providence Health & Rehab Center's Medicare star rating?
CMS rates Providence Health & Rehab Center 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Providence Health & Rehab Center get at its last inspection?
30 health deficiencies at the standard inspection on August 7, 2026. The Pennsylvania average is 10.
Has Providence Health & Rehab Center been fined?
Yes. CMS lists 11 fines totaling $56,804 in the last three years.
Does Providence 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 Providence Health & Rehab Center?
CMS lists 26 owners and managers, and links the home to Saber Healthcare Group. Legal business name: PROVIDENCE HEALTH & REHAB CENTER, LLC.

Sources

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