Home / Pennsylvania / Erie
Twinbrook Healthcare and Rehabilitation Center
3805 Field Street, Erie, PA 16511 · Erie County · (814) 898-5600
118 certified beds, about 101 residents a day · For profit - Corporation · Medicare and Medicaid since 1967
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395041 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 16, 2026, inspectors cited 10 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
None of its 37 health citations since May 2024 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
CMS links it to Pollak Holdings, an affiliated group of 6 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.
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 37 health citations on file.
April 16, 2026Standard inspection · 10 citations
- E Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for nine of 28 residents reviewed (Residents R5, R7, R8, R15, R17, R84, R94, R105, and R109).
- E Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for six of 28 residents reviewed (Residents R1, R10, R55, R56, R94, and R109).
- E Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for three residents reviewed with respiratory care (Residents R1, R5, and R15).
- 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.
Inspectors wroteBased on review of facility policy, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened and failed to ensure an expired medication was discarded in a timely manner in two of three medication carts reviewed (East Two Cart and South Cart).
- D Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for two of 28 residents reviewed (Residents R10 and R56).
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to transcribe a physician order for turning and repositioning for one resident reviewed (Resident R5).
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of the facility documents and clinical records, and resident and staff interview, it was determined that the facility failed to maintain complete and accurate records relating to dialysis (a medical procedure that filters blood when the kidneys are not functioning properly) communication for one of two residents reviewed for dialysis (Resident R8).
- D Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during visits for one of 28 residents reviewed (Resident R94).
- D Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on review of clinical records, resident interviews and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least once every 30 days for the first 90 days after admission and at least 60 days thereafter for one of 28 residents reviewed (Resident R94).
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during observation of a resident with a foley catheter (tubing inserted into the bladder to drain urine) (Resident R7), and failed to prevent the potential for cross-contamination (transfer of germs from one location to another) for one resident receiving nebulizer treatments (a treatment that delivers medication directly to the lungs to treat respiratory conditions) (Resident R15).
March 10, 2026Complaint inspection · 2 citations
- E Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure adequate assistance and supervision with meals was provided for one of four residents observed in the [NAME] Dining Room (Resident R1); failed to ensure assessment of a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment for a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for five of 26 residents (Residents R3, R4, R5, R6, and R7); and failed to ensure nutritional interventions were implemented for two of 26 residents reviewed (Residents R8 and R9).
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure the physician was notified timely regarding laboratory studies for one of four residents reviewed (Resident R2).
February 12, 2026Complaint inspection · 2 citations
- C 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.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a sanitary, orderly, and comfortable interior/homelike environment for two of five nursing units observed (East 1 and [NAME] units).
- C Post nurse staffing information every day.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure that the required nursing staffing information was posted on a daily basis.
June 12, 2025Complaint inspection · 1 citation
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of facility policy, facility documents, and clinical records, and staff interviews, it was determined that the facility failed to have sufficient staff with the appropriate skill sets to provide nursing services.
April 25, 2025Standard inspection, Complaint inspection · 10 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, review of dishwashing machine manufacturer's instructions, and staff interviews, it was determined that the facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for five of five resident units (South East, South, West, East One and East Two units). The facility also failed to prevent the potential for cross-contamination during medication administration and completion of a wound dressing change for two of 21 residents reviewed (Residents R81 and Resident R92).
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to assure physician orders and resident's Pennsylvania Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 24 residents reviewed (Resident R78).
- 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.
Inspectors wroteBased on review of facility policy, observations, and resident and staff interview, it was determined that the facility failed to maintain a clean and sanitary resident room for three of three rooms (rooms [ROOM NUMBER]).
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for two of seven residents reviewed (Residents R59 and R92).
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop comprehensive care plans for one of 21 residents reviewed (Resident R92).
- 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.
Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of three residents reviewed (Resident R92).
- D Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to have a Director of Nursing (DON) working full-time of 35 hours per week in the building.
- 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.
Inspectors wroteBased on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for three of three medication carts reviewed and one of three medication rooms reviewed (West, East One, and South medication carts and East One medication room).
- C Post nurse staffing information every day.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure that the required nursing staffing information was posted on a daily basis.
December 23, 2024Complaint inspection · 3 citations
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to follow physician's orders related to laboratory blood draws for three of the four residents reviewed for laboratory testing (Residents R1, R2, and R3).
- E Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on review of facility policy, clinical records, and facility documents, observations, and staff interview, it was determined that the facility failed to ensure an organized system and adequate supplies were in place for timely and accurate laboratory services for four of four residents reviewed for laboratory testing (Residents R1, R2, R3, and R4).
- 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.
Inspectors wroteBased on observations, review of facility policy, and staff interview, it was determined that the facility failed to maintain a homelike environment for one of nine residents reviewed (Resident R5).
October 24, 2024Complaint inspection · 1 citation
- E Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure that physicians wrote, signed, and dated progress notes at required visits for six of six residents reviewed (Residents R1, R2, R3, R4, R5, and R6).
May 17, 2024Standard inspection · 8 citations
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement resident centered comprehensive care plans for four of 20 residents reviewed (Residents R19, R51, R54, and R66).
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for three of 20 residents reviewed (Residents R4, R20, and R58).
- E Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and prevent the potential spread of infection regarding respiratory care equipment according to physician's orders for six of 20 residents (Residents R4, R19, R51, R54, R58, and R66).
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide resident privacy and dignity regarding an exposed urinary catheter (a tube placed and held in the bladder to drain urine) bag for two of two residents reviewed for catheters (Residents R8 and R69).
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 20 residents reviewed (Resident R60).
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of manufacturer's recommendations, facility policy, and clinical records, and staff interviews it was determined that the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one of 20 residents reviewed (Resident R19).
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a review of facility policy and clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate and safe disposition of controlled medication records for one of three closed records reviewed (Resident CR94).
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a pharmacist's recommendation was reviewed and acted upon for one of 20 residents reviewed (Resident R19).
Fire safety inspections
16 fire safety citations on file: 6 on April 16, 2026, 5 on April 25, 2025, 5 on May 17, 2024.
Every fire safety citation16 citations
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Have proper medical gas storage and administration areas.
- B Properly select, install, inspect, or maintain portable fire extinguishes.
- B Have power receptacles that are properly grounded.
- E Install a two-hour-resistant firewall separation.
- E Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- B Use approved construction type or materials.
- B Properly select, install, inspect, or maintain portable fire extinguishes.
- B Have power receptacles that are properly grounded.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Install corridor and hallway doors that block smoke.
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Have simulated fire drills held at unexpected times.
- C Meet other general requirements.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 3.89 | 3.86 |
| Registered nurses | not reported | 0.79 | 0.69 |
| All nursing staff on weekends | not reported | 3.53 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | not reported | 44.5% | 45.8% |
| Registered nurse turnover | not reported | 39.9% | 42.9% |
| Administrators who left | not reported |
CMS note on this home's staffing data: This facility submitted data that did not meet the criteria required to calculate a staffing measure.
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 October to December 2025, nursing staff hours per resident were 3.83 on weekdays and 3.52 on weekends, 8% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 13.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.54 in April to June 2025 to 3.74 in October to December 2025.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Oct to Dec 2025 | 3.74 | 0.58 | 3.83 | 3.52 | 13.2% | 0 of 92 | 96 |
| Jul to Sep 2025 | 3.51 | 0.47 | 3.60 | 3.28 | 19.7% | 0 of 92 | 99 |
| Apr to Jun 2025 | 3.54 | 0.41 | 3.64 | 3.28 | 14.7% | 0 of 91 | 95 |
| United States, Oct to Dec 2025 | 3.76 | 0.62 | 3.93 | 3.34 | 5.3% | 0.5% of days | |
| Pennsylvania, Oct to Dec 2025 | 3.71 | 0.65 | 3.85 | 3.36 | 10.9% | 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.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.6 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.7 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.7 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 12.6 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.3 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 29.6 | 17.7 | 15.4 |
Owners and operators
Legal business name: TWINBROOK OPCO LLC. CMS links this home to Pollak Holdings, a group of 6 nursing homes averaging 1.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Hersh, Deena | Direct ownership interest | Individual | 04/23/2021 | |
| Pollak, Elie | Managing control - governing body | Individual | 04/23/2021 | |
| Carter, Seth | Operational/managerial control | Individual | 01/01/2025 | |
| Marquetti, Elena | Operational/managerial control | Individual | 01/01/2025 | |
| Carter, Seth | Adp of the SNF | Individual | 12/18/2025 | |
| Marquetti, Elena | Adp of the SNF | Individual | 12/18/2025 |
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.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 8 problems in this area, most recently on April 16, 2026: "Provide safe and appropriate respiratory care for a resident when needed."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on April 16, 2026: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 7 problems in this area, most recently on April 16, 2026: "Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit."
- When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on April 16, 2026: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
Other nursing homes nearby
- Ball Pavilion, the Erie, 2 mi · 5 of 5 stars · 11 citations
- Pennsylvania Soldiers and Sailors Home Erie, 3.1 mi · 5 of 5 stars · 10 citations
- Nightingale Nursing and Rehab Center Erie, 3.1 mi · 3 of 5 stars · 12 citations
- Lecom at Village Square, LLC Erie, 4 mi · 4 of 5 stars · 17 citations
- Sarah Reed Senior Living Erie, 4.1 mi · 5 of 5 stars · 10 citations
- Lecom at Elmwood Gardens, LLC Erie, 5.4 mi · 5 of 5 stars · 7 citations
- Greenfield Healthcare and Rehabilitation Center Erie, 6.3 mi · 1 of 5 stars · 54 citations
- Millcreek Manor Erie, 6.5 mi · 4 of 5 stars · 29 citations
Pennsylvania contacts for a concern about a nursing home
These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Pennsylvania Department of Health, Division of Nursing Care Facilities, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Pennsylvania Long-Term Care Ombudsman Program, Department of Aging, 717-783-8975. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Pennsylvania Department of Health Nursing Care Facility Locator, where Pennsylvania publishes its own records on licensed homes.
Common questions
- What is Twinbrook Healthcare and Rehabilitation Center's Medicare star rating?
- CMS rates Twinbrook Healthcare and Rehabilitation Center 2 out of 5 stars overall, with 2 for health inspections, no for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Twinbrook Healthcare and Rehabilitation Center get at its last inspection?
- 10 health deficiencies at the standard inspection on April 16, 2026. The Pennsylvania average is 10.
- Has Twinbrook Healthcare and Rehabilitation Center been fined?
- CMS lists no fines in the last three years.
- Does Twinbrook Healthcare and Rehabilitation 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 Twinbrook Healthcare and Rehabilitation Center?
- CMS lists 6 owners and managers, and links the home to Pollak Holdings. Legal business name: TWINBROOK OPCO LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.