Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belvedere Center, Genesis Healthcare, The during CMS and state inspections, most recent first.
Insulin pens on multiple med carts were improperly labeled and stored. Surveyors found open Lispro, Humalog, Lantus, Basaglar, and Glargine pens without open or expiration dates, one Glargine pen without a resident name, and several unopened Humalog, Lantus, and Glargine pens left unrefrigerated; the findings were reported to the DON.
Failure to notify the Ombudsman of a hospital transfer. A resident was transferred to the hospital for a change in condition and decline in ADLs, but the facility had no documented evidence that written notice was sent to the Ombudsman. The discharge log also did not list the resident’s hospital transfer, and the DON confirmed there was no documentation of notification.
Failure to complete a significant change MDS after hospice admission. A resident had a hospice order, was assessed by hospice, and later admitted to hospice after an initial admission was voided. Although a significant change MDS was completed once, it did not reflect hospice care, and no new significant change MDS was completed after hospice actually began.
The facility failed to ensure accurate MDS coding for two residents. One resident was receiving dialysis, but the quarterly MDS indicated dialysis was not being provided, and another resident was receiving hospice care, but the admissions MDS indicated hospice care was not being provided. Licensed staff confirmed both assessments were coded incorrectly.
A resident with hypotension had an order for Midodrine 10 mg via PEG tube three times daily, with instructions to hold the dose when SBP was 130 or higher. The MAR showed the medication was given multiple times outside those parameters, including 11 administrations in one month and 9 in the next, despite SBP readings at or above the hold threshold.
An unlocked North Hall Front medication cart was observed unattended while four residents were in the hallway. The cart could be opened, and medications were visible to the surveyor while an LPN was in a resident room with their back turned and unable to observe the cart.
A resident with dementia and other health issues developed a Stage 3 pressure ulcer due to the facility's failure to monitor skin condition and follow wound treatment orders. Despite being at risk, the resident's wound was not treated as prescribed, leading to deterioration and hospital transfer for osteomyelitis treatment.
A facility failed to maintain the dignity of a resident by displaying a 'FALL RISK' sign on their door without consent. The resident, who has moderate cognitive impairment and communication difficulties due to a brain hemorrhage, had the sign displayed for several days. The NHA confirmed the lack of consent, acknowledging the failure to respect the resident's dignity.
A facility failed to ensure accurate documentation of a resident's advanced directives. The resident, with severe cognitive impairment and multiple health issues, had conflicting records: a care plan indicating Full Code and physician orders stating DNR, DNI, and DNH. No explanation for this discrepancy was found in the progress notes, as confirmed by the DON.
A facility failed to develop a baseline care plan for a resident readmitted with acute diastolic congestive heart failure and requiring continuous oxygen therapy. Despite physician orders for specific oxygen management, the care plan lacked necessary details for the resident's oxygen needs. This was confirmed through clinical record review and a DON interview.
A facility failed to develop a comprehensive care plan for a resident identified as an elopement risk. Despite assessments indicating the risk, the care plan lacked measures to address it. This deficiency was confirmed with the DON.
A resident with mild cognitive impairment and identified as an elopement risk left a medical appointment unsupervised. Despite a care plan involving the resident's Power of Attorney for escorting to appointments, the resident left the facility before the Power of Attorney arrived, indicating inadequate supervision.
A resident with an indwelling catheter did not receive documented catheter care after the physician's order was discontinued. Despite the order being discontinued, the resident still had the catheter, and there was no evidence of care provided. The DON confirmed the lack of documentation and care, violating clinical record and resident care policies.
A resident with dementia and a left femur fracture experienced two unwitnessed falls with no observed injuries. Later, an x-ray revealed a fracture in the resident's left foot, which the facility failed to investigate, assuming it was pre-existing from the hospital. The Nursing Home Administrator confirmed no investigation was conducted, and no documentation supported the fracture's origin prior to admission.
The facility failed to follow a physician's order for vital signs monitoring and did not notify the physician of an x-ray result in a timely manner for a resident with dementia, a femur fracture, and pneumonia. The resident's vital signs were checked only once daily instead of twice, and the physician was not promptly informed of a foot fracture revealed by an x-ray.
Insulin Pens Improperly Labeled and Stored on Medication Carts
Penalty
Summary
The facility failed to ensure medications were properly labeled with open and expiration dates for three of four medication carts observed. Surveyors reviewed package insert instructions showing that unopened Humalog insulin pens should be stored in the refrigerator, that opened Humalog pens may be kept at room temperature for up to 28 days, and that Lantus insulin should be used within 28 days after opening. On observation of the North Back Hall medication cart, surveyors found one open Lispro insulin pen with no open or expiration date, three open Lantus insulin pens with no open or expiration date, one unopened and unrefrigerated Lispro insulin pen, two open Humalog insulin pens with no open or expiration date, one Glargine insulin pen with no resident name and no open or expiration date, and one unopened Glargine insulin pen unrefrigerated. On the North Front Hall medication cart, surveyors found one unopened Lantus insulin pen unrefrigerated. On the South Hall Middle medication cart, surveyors found one open Lantus insulin pen with no open or expiration date, one open Basaglar insulin pen with no expiration date, and one unopened Humalog insulin pen unrefrigerated. The findings were conveyed to the DON.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident’s transfer to the hospital. Facility policy titled Discharge and Transfer, dated June 11, 2025, stated that for unplanned, acute hospital transfers, the resident must be permitted to return to the facility, the resident and resident representative must be notified verbally and then in writing using the Notice of Hospital Transfer or state-specific transfer form, and copies of notices for emergency transfers must also be sent to the Ombudsman when practicable. Review of Resident 134’s clinical record showed the resident was transferred to the hospital on July 21, 2025, due to a change in condition and decline in activities of daily living. There was no documented evidence that the facility provided written notice to the Ombudsman regarding the hospitalization, and the facility’s discharge log for July 1 through July 31, 2025 did not list Resident 134 as discharging to the hospital on July 21, 2025. During interview, the NHA and DON confirmed there was no documentation that the Ombudsman’s Office had been notified of the resident’s hospital transfer.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days after a significant change in condition for Resident 90. The resident had a physician order on June 19, 2025, for Compassus Hospice evaluation and treatment, and a progress note on June 20, 2025, documented that the resident was assessed by Compassus Hospice and admitted to their services. A significant change MDS was completed on June 20, 2025, but Section O0110 indicated the resident was not receiving hospice care. A later progress note on June 23, 2025, stated that the hospice nurse reported the resident’s earlier admission had been voided and that the resident was admitted to hospice on June 23, 2025. The clinical record showed that no significant change MDS was completed after the resident was admitted to hospice. During interview, Employee E3 confirmed that hospice started on June 23, 2025, and that a significant change MDS had not been completed.
Inaccurate MDS Coding for Dialysis and Hospice Services
Penalty
Summary
The facility failed to ensure accurate assessments for two residents. Resident 95 was receiving dialysis, but the quarterly MDS assessment dated July 3, 2025, Section O0110 Special Treatments, Procedures, and Programs, indicated that the resident was not receiving dialysis. Licensed staff confirmed on August 15, 2025, that Resident 95 was receiving dialysis and that the MDS was coded incorrectly. Resident 113 was receiving hospice care, but the admissions MDS assessment, Section O0110 Special Treatments, Procedures, and Programs, indicated that the resident was not receiving hospice care. Licensed staff confirmed on August 15, 2025, that Resident 113 was receiving hospice care and that the MDS was coded incorrectly.
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident. Resident 3 had a current order for Midodrine HCl 10 mg via PEG tube three times daily for hypotension, with instructions to hold the medication for systolic blood pressure greater than or equal to 130. Review of the medication administration record showed that Midodrine was administered 11 times in June 2025 and 9 times in July 2025 outside of the ordered parameters, with systolic blood pressure readings greater than or equal to 130. The report also notes that the medication administration guidelines required medications to be administered in accordance with written prescriber orders.
Unattended Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure that medication carts were locked when a staff member was not in attendance for one of four medication carts observed, identified as the North Hall Front Cart. During an observation on August 15, 2025, at 9:16 a.m., the North Hall Front Medication Cart was found open and unlocked with no staff members present. Four residents were observed in the hallway at the time. The cart could be opened during the observation, and medications were able to be viewed and examined by a surveyor. A licensed employee was observed in a resident room with their back to the cart and unable to observe the unattended, unlocked cart. The issue was reported to the DON on August 15, 2025, at 11:00 a.m.
Failure to Monitor Skin and Follow Treatment Orders Leads to Wound Deterioration
Penalty
Summary
The facility failed to monitor a resident's skin condition and follow the wound physician's treatment orders, resulting in harm to the resident. The resident, who had dementia, a urinary tract infection, and peripheral vascular disease, was admitted without any pressure ulcers but was at risk for developing them. Despite weekly skin assessments, a new Stage 3 pressure ulcer was discovered on the resident's sacrum, indicating a failure in early detection and intervention. The wound physician's orders to treat the sacral wound daily were not followed, as the treatment was administered every other day instead. This non-compliance with the physician's orders led to the wound's deterioration, as evidenced by the wound consult reports showing the wound's progression from Stage 3 to unstageable with increased slough and eschar. The wound nurse confirmed that the treatment orders were not followed, contributing to the resident's worsening condition. The resident's condition deteriorated further, with the wound becoming malodorous and painful, leading to a hospital transfer where early coccygeal osteomyelitis was diagnosed. The wound required surgical debridement and IV antibiotics. The facility's failure to ensure proper skin monitoring and adherence to treatment orders resulted in significant harm to the resident, including wound deterioration and unnecessary pain.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 80, by displaying a sign on the resident's door indicating 'FALL RISK' without obtaining consent from the resident or their Power of Attorney (POA). Resident 80, who has a BIMS score of 8 indicating moderate cognitive impairment, also has difficulty understanding and communicating with others due to an active diagnosis of Other Nontraumatic Intracerebral Hemorrhage. Observations on three consecutive days revealed that the sign remained on the resident's door. The Nursing Home Administrator confirmed that the facility did not have consent to display the sign, acknowledging the failure to respect the resident's dignity.
Inconsistent Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that the advanced directives for a resident were accurately reflected in the resident's records. The resident, who was admitted with multiple diagnoses including chronic kidney disease, prostate cancer, and severe cognitive impairment, had conflicting documentation regarding their advanced directives. A care plan dated January 24, 2023, indicated the resident had an advanced directive of Full Code, while a subsequent care plan dated April 12, 2024, noted the resident was admitted to hospice care with a goal related to end-of-life acceptance. However, the active physician orders from April 10, 2024, indicated the resident's advanced directive was Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH). There was no documentation in the progress notes from April 10, 2024, through July 18, 2024, explaining the discrepancy between the physician's orders and the care plan. This inconsistency was confirmed during an interview with the Director of Nursing on July 18, 2024.
Failure to Develop Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was readmitted with acute diastolic congestive heart failure, hypertension, and an absence of the left leg above the knee. The resident required continuous oxygen therapy at 2L/min via nasal cannula, as documented in physician orders. These orders included monitoring pulse oxygen every shift to maintain oxygen saturation levels at or above 90%, cleaning the external filter on the oxygen concentrator, and changing the oxygen tube weekly with proper labeling. Despite these requirements, the resident's care plan did not include a baseline care plan for the oxygen therapy. This deficiency was identified during a review of the resident's clinical records and confirmed in an interview with the Director of Nursing.
Failure to Address Elopement Risk in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident identified as being at risk for elopement. The clinical record review revealed that the resident, referred to as Resident 113, had an admission elopement assessment indicating a score of 6, which classified the resident as an elopement risk. A subsequent elopement assessment also indicated a score of 1, maintaining the resident's status as an elopement risk. Despite these assessments, the resident's care plan did not include any measures or strategies to address the risk of elopement. These findings were confirmed with the Director of Nursing during a discussion on July 18, 2024, at 10:05 a.m. The deficiency was noted under the regulations 28 Pa. Code 211.5(f) concerning clinical records and 28 Pa. Code 211.12(d)(1)(5) regarding nursing services.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as an elopement risk. The resident, who was admitted with diagnoses including altered mental status and schizophrenia, initially had no cognitive impairment but later showed mild cognitive impairment. Despite being identified as an elopement risk in assessments, the resident was allowed to attend a medical appointment without a staff escort, as per a transportation agreement signed earlier. The resident's Power of Attorney had agreed to escort the resident to medical appointments, but on the day of the incident, the resident left the vascular surgery center before the Power of Attorney arrived. On the day of the incident, the resident was scheduled for a vascular appointment at 10:30 a.m. The facility received a call at 11:00 a.m. from the surgery center, reporting that the resident had left the building after checking in. A witness statement from the transport driver confirmed seeing the resident walking down the street. This incident highlights the facility's failure to ensure adequate supervision and adherence to the care plan, which included the involvement of the resident's Power of Attorney for medical appointments.
Failure to Provide Catheter Care for a Resident
Penalty
Summary
The facility failed to provide necessary catheter care for a resident, identified as Resident 90, who had an indwelling catheter. According to the clinical record review, there was a physician's order dated January 16, 2024, for the resident to receive catheter care every day and night shift. This order was discontinued on April 17, 2024. However, an observation on July 15, 2024, revealed that the resident still had an indwelling catheter, and there was no documented evidence of catheter care being provided since the order was discontinued. An interview with the Director of Nursing on July 18, 2024, confirmed that Resident 90 had an indwelling catheter and that there was no documentation of catheter care since April 17, 2024. This lack of documentation and care was a violation of the facility's clinical record and resident care policies, as well as nursing services regulations.
Failure to Investigate Injury of Unknown Cause
Penalty
Summary
The facility failed to comprehensively investigate an injury of unknown cause for a resident diagnosed with dementia and a fracture of the left femur. The resident experienced two unwitnessed falls on December 22 and December 24, 2023, with no injuries observed at the time. However, on December 29, 2023, the resident's daughter-in-law requested an x-ray due to the resident's complaint of pain when the foot was massaged. The x-ray revealed an acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. Despite this finding, the facility did not investigate the origin of the fracture, assuming it was present from the hospital based on the family's report and the resident's reaction to touch. The Nursing Home Administrator confirmed that no investigation was conducted regarding the left foot fracture identified on December 29, 2023. The facility could not provide documentation indicating that the fracture occurred prior to the resident's admission. This lack of investigation into the injury of unknown origin constitutes a failure to ensure comprehensive care and safety for the resident.
Failure to Follow Physician's Orders and Timely Notify Physician
Penalty
Summary
The facility failed to follow a physician's order regarding vital signs monitoring and did not notify the physician of an x-ray result in a timely manner for a resident. The resident had a diagnosis of dementia, a fracture of the left femur, and pneumonia. An x-ray was ordered for the resident's left foot due to pain, revealing an acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. The radiology report was placed in the physician's book for review, but the physician was not notified immediately. The physician only became aware of the fracture during a follow-up visit several days later, leading to a delay in appropriate care instructions, such as non-weight bearing and specialist evaluation. Additionally, the facility did not adhere to a physician's order to check the resident's vital signs twice daily for pneumonia. The clinical records showed that vital signs were only checked once daily over several days, contrary to the physician's order. This was confirmed by the Assistant Director of Nursing, who acknowledged that the order was not followed as required.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wallingford Skilled Nursing And Rehabilitation Cen | 2 mi | ★★★★★ | 1 | 0 |
| Aventura At Prospect | 3.1 mi | ★★★★★ | 16 | 0 |
| Monticello House | 3.2 mi | ★★★★★ | 0 | 0 |
| Sterling Health Care And Rehab Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Springfield Rehabilitation And Healthcare Center | 4.1 mi | ★★★★★ | 10 | 0 |
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