Cycle 1
Health 2025-06-06 · Fire 2025-06-06
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Kingston, PA
Edenbrook On Second Ave
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
200 Second Avenue, Kingston, PA
(570) 288-9315
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
0
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eden East Healthcare Management
Operator or chain grouping
Approved since
1977-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,411
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.30% · Performance 22.52% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.45
Baseline 5.94% · Performance 7.10% · Measure score 2.45 · Achievement 2.45 · Improvement 0
Total nurse turnover
0
Baseline 65.75% · Performance 66.91% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.51
Baseline 3.56 hours · Performance 3.79 hours · Measure score 2.51 · Achievement 2.51 · Improvement 0.56
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.69% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 9.01% · Lower 95% interval 6.68% |
| Discharge to community | 41.58% |
50.57%
9 pts worse
|
Worse than the National Rate · Eligible stays 103 · Observed rate 32.04% · Lower 95% interval 33.25% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 79 · Denominator 79 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 79 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 36 · Denominator 54 |
| Discharge mobility score | 55.56% |
50.94%
4.6 pts better
|
Numerator 30 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 3.8% |
2.29%
1.5 pts worse
|
Numerator 3 · Denominator 79 · Adjusted rate 2.66% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 63 · Observed rate 7.94% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 26.85% |
8.2%
18.7 pts better
|
Numerator 40 · Denominator 149 |
| Staff flu vaccination coverage | 15.72% |
42%
26.3 pts worse
|
Numerator 25 · Denominator 159 |
| Discharge function score | 72.22% |
56.45%
15.8 pts better
|
Numerator 39 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 11.54% |
25.2%
13.7 pts worse
|
Numerator 3 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
86.9%
9.2 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 99.2% · Q3 95.0% · Q4 93.2% · 4Q avg 96.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.5%
2.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.3% · Q3 3.3% · Q4 2.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
6.5%
2.2 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 2.7% · Q3 1.8% · Q4 4.9% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
19.9%
1.4 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.5% · Q3 23.7% · Q4 23.1% · 4Q avg 21.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
18.7%
2.8 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 23.3% · Q3 25.8% · Q4 19.1% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.7% |
19.6%
5.1 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 29.3% · Q3 8.7% · Q4 26.3% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
18.3%
3.7 pts better
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 5.7% · Q3 10.4% · Q4 25.0% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
26.4%
3 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 38.9% · Q3 21.8% · Q4 24.6% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.3%
2.1 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 7.2% · Q3 7.7% · Q4 5.9% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.3% |
68.9%
12.4 pts better
|
81.7%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 81.3% · Q3 83.8% · Q4 71.1% · 4Q avg 81.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
9.8%
6.5 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 17.3% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
68.7%
13.4 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
23.1%
6.3 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 28.8% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-23 · Fire 2024-08-23
21 health deficiencies
Top issue: Resident Rights (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2024-03-15 · Fire 2024-03-15
31 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-23
E · Potential for more than minimal harm
2024-08-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-03-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-03-03
F · Potential for more than minimal harm
2025-09-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-11-04
E · Potential for more than minimal harm
2025-09-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-11-04
E · Potential for more than minimal harm
2025-06-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-06
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-02-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-01-10
F560 · Resident Rights Deficiencies
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-08-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-23
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-23
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-05-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-05-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-05-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-05-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-03-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-03-15
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-03-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-03-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-03-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-03-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-03-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-03-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-05-15
E · Potential for more than minimal harm
2023-09-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-31
G · Actual harm
2023-07-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-07-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-05-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-30
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-30
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-02
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-02
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-04
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-05-02
E · Potential for more than minimal harm
2023-03-10
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-02
E · Potential for more than minimal harm
2023-03-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-02
E · Potential for more than minimal harm
2023-03-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-02
E · Potential for more than minimal harm
2023-03-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-03-10
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-03-10
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-03-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-03-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-02
Penalties and ownership
What sits behind the stars
Ownership
Lz Pa Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Zahler, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
W-2 Managing Employee · Individual
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