F54

INNERS CREEK SKILLED NURSING AND REHABILITATION CE

Grade F 54/100 composite score

For profit - CorporationAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
2/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

202

Ownership

For profit - Corporation

Total Fines

$32,679

Last Survey

N/A

100 WEST QUEEN STREET, DALLASTOWN, PA 17313
7172461671

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.46h
LPN
0.91h
CNA
1.99h
Total
3.36h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

GENESIS PM PA OPERATIONS LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Nov 2022

100%

FC-GEN OPERATIONS INVESTMENT LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

GEN OPERATIONS I LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

GEN OPERATIONS II LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

GENESIS HEALTHCARE INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

GENESIS HEALTHCARE LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

GENESIS HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

GHC HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

HCCF MANAGEMENT GROUP XI LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

SUN HEALTHCARE GROUP INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

SUNDANCE REHABILITATION HOLDCO INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

WELLTOWER OP LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

ZAC PROPERTIES XI LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Nov 2022

MORRIS, DIANE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2024

PATEL, PURVI

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2025

SPARVER, BRANDON

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2024

BERG, MICHAEL

IndividualCORPORATE OFFICERSince Nov 2022

BRIDGEFORD, LAURA

IndividualCORPORATE OFFICERSince Jun 2024

MENDELSON, AVI

IndividualCORPORATE OFFICERSince Jun 2024

Penalties & Fines (1)

$32,679total fines
DateTypeDescriptionAmount
Sep 11, 2024Fine$32,679

Health Inspection Deficiencies (55)

September 16, 2025Health1 deficiency1 severe
0600GActual harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Oct 7, 2025
August 7, 2025Health1 deficiency
0692EMinimal harm, Pattern

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Sep 5, 2025
July 17, 2025Health3 deficiencies
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 21, 2025
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 21, 2025
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Aug 21, 2025
June 9, 2025Health2 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jun 27, 2025
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Jun 29, 2025
May 7, 2025Health1 deficiency
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected May 23, 2025
May 2, 2025Health1 deficiency
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 23, 2025
December 23, 2024Health2 deficiencies
0711DMinimal harm, Isolated

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Nursing and Physician Services Deficiencies

Corrected Jan 23, 2025
0726DMinimal harm, Isolated

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.

Nursing and Physician Services Deficiencies

Corrected Jan 23, 2025
November 20, 2024Health2 deficiencies
0776DMinimal harm, Isolated

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Administration Deficiencies

Corrected Dec 3, 2024
0777DMinimal harm, Isolated

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

Administration Deficiencies

Corrected Dec 3, 2024
October 25, 2024Health16 deficiencies1 severe
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Dec 3, 2024
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Dec 3, 2024
0604EMinimal harm, Pattern

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 3, 2024
0625DMinimal harm, Isolated

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies

Corrected Dec 3, 2024
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Dec 3, 2024
0692EMinimal harm, Pattern

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Dec 3, 2024
0730EMinimal harm, Pattern

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Dec 3, 2024
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Dec 3, 2024
0756EMinimal harm, Pattern

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Dec 3, 2024
0758EMinimal harm, Pattern

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Dec 3, 2024
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Dec 3, 2024
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Dec 3, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 3, 2024
0947EMinimal harm, Pattern

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies

Corrected Dec 3, 2024
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 3, 2024
0805KImmediate jeopardy, Pattern

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Corrected Dec 3, 2024
September 11, 2024Health1 deficiency
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 30, 2024
March 7, 2024Health2 deficiencies
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Apr 16, 2024
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Apr 16, 2024
November 30, 2023Health21 deficiencies
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jan 17, 2024
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Jan 17, 2024
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Jan 17, 2024
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Jan 17, 2024
0625DMinimal harm, Isolated

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies

Corrected Jan 17, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 17, 2024
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Jan 17, 2024
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 17, 2024
0657EMinimal harm, Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 17, 2024
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 17, 2024
0675DMinimal harm, Isolated

Honor each resident's preferences, choices, values and beliefs.

Quality of Life and Care Deficiencies

Corrected Jan 17, 2024
0686EMinimal harm, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jan 17, 2024
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Jan 17, 2024
0730EMinimal harm, Pattern

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Jan 17, 2024
0732CNo harm, Widespread

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Jan 17, 2024
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Jan 17, 2024
0758EMinimal harm, Pattern

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Jan 17, 2024
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jan 17, 2024
0838FMinimal harm, Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies

Corrected Jan 17, 2024
0849EMinimal harm, Pattern

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Administration Deficiencies

Corrected Jan 17, 2024
0947EMinimal harm, Pattern

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies

Corrected Jan 17, 2024
December 8, 2022Health2 deficiencies
0641EMinimal harm, Pattern

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 26, 2022
0657EMinimal harm, Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 26, 2022

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Frequently Asked Questions

What is the CareGrader rating for INNERS CREEK SKILLED NURSING AND REHABILITATION CE?

INNERS CREEK SKILLED NURSING AND REHABILITATION CE in DALLASTOWN, Pennsylvania has a CareGrader grade of F (Poor), with a composite score of 54.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for INNERS CREEK SKILLED NURSING AND REHABILITATION CE?

INNERS CREEK SKILLED NURSING AND REHABILITATION CE has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does INNERS CREEK SKILLED NURSING AND REHABILITATION CE have?

INNERS CREEK SKILLED NURSING AND REHABILITATION CE has 55 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has INNERS CREEK SKILLED NURSING AND REHABILITATION CE been fined?

Yes. INNERS CREEK SKILLED NURSING AND REHABILITATION CE has $32,679 in total fines from CMS enforcement actions across 1 penalty.

How many beds does INNERS CREEK SKILLED NURSING AND REHABILITATION CE have?

INNERS CREEK SKILLED NURSING AND REHABILITATION CE has 202 certified beds with approximately 191 current residents (95% occupancy). The facility is located at 100 WEST QUEEN STREET, DALLASTOWN, Pennsylvania 17313. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.