20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
York, PA
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
970 Colonial Avenue, York, PA
(717) 845-2661
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
270
Certified beds
Average residents
192
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.55
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.07
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
5,519
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.78
Baseline 17.97% · Performance 18.75% · Measure score 5.78 · Achievement 5.78 · Improvement 0
Healthcare-associated infections
4.63
Baseline 5.91% · Performance 6.45% · Measure score 4.63 · Achievement 4.63 · Improvement 0
Total nurse turnover
2.57
Performance 53.16% · Measure score 2.57 · Achievement 2.57 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.39
Baseline 3.34 hours · Performance 3.47 hours · Measure score 1.39 · Achievement 1.39 · Improvement 0.03
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.32% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 6.45% |
| Discharge to community | 45.25% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 35.71% · Lower 95% interval 35.14% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 92.11% |
95.27%
3.2 pts worse
|
Numerator 35 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 13 · Denominator 26 |
| Discharge mobility score | 15.38% |
50.94%
35.6 pts worse
|
Numerator 4 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 176 |
| Staff flu vaccination coverage | 15.25% |
42%
26.8 pts worse
|
Numerator 27 · Denominator 177 |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 12 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 2 · Denominator 22 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
86.9%
9.8 pts better
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 96.0% · Q4 92.0% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
93.5%
3.8 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.2%
0.9 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.2% · Q3 1.7% · Q4 2.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
6.5%
5.3 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 4.4% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
6.5%
About the same
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.0% · Q3 7.1% · Q4 8.6% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
19.9%
6.8 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 13.8% · Q3 14.7% · Q4 13.2% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 37.2% |
18.7%
18.5 pts worse
|
16.7%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 38.0% · Q3 37.4% · Q4 36.9% · 4Q avg 37.2% · 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 | 19.1% |
19.6%
0.5 pts better
|
16.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 16.2% · Q3 21.0% · Q4 19.1% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
18.3%
1 pts better
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 15.2% · Q3 18.6% · Q4 19.0% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 2.3% · Q4 1.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.8% · Q3 4.0% · Q4 1.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
26.4%
2.9 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 22.9% · Q3 31.2% · Q4 31.0% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.3%
0.6 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.9% · Q3 5.5% · Q4 3.6% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.4% |
68.9%
14.5 pts worse
|
81.7%
27.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.3% · Q2 63.4% · Q3 48.4% · Q4 40.8% · 4Q avg 54.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.3% |
9.8%
7.5 pts better
|
12.0%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.3% · Observed 2.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
1.5%
4.7 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.5% · Q3 6.6% · Q4 4.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.1% |
68.7%
20.6 pts worse
|
79.7%
31.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.0% |
23.1%
10.1 pts better
|
23.9%
10.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 14.6% · Expected 26.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Nutrition and Dietary (8 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-27
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-27
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-07-29
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-29
Fire Safety
Meet other general requirements.
Corrected 2024-07-29
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-29
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-29
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-09-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-05
Inspection history
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-16
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 2025-12-16
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-10-01
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 2025-07-08
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-08
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-08
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-07-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-08
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-08
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-08
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-08
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2025-07-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-08
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-08
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-07-08
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-08
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-01
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-01
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-01
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 2024-07-01
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-07-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-01
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-07-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-01
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-07-01
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-01
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-07-01
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 2024-06-03
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-03
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-15
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-03
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
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-11-27
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-27
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 2023-10-02
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-02
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-10-02
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-02
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-02
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-10-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-02
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-02
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-02
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-02
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-02
Health
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.
Corrected 2023-10-02
Health
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.
Corrected 2023-10-02
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 2023-10-02
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-02
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-12
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-06-12
Health
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.
Corrected 2023-06-12
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Nearby options
York, PA
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
York, PA
3-star overall rating with 4-star inspections with $15,382 in total fines with 4 recent health deficiencies
York, PA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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