Your report for Delaware Valley Skilled Nursing & Rehabilitation C
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- PennsylvaniaAbove only 42% of peers653 rated homes · average 3.0★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point3★+0.2 vs PA avg
- StaffingCan add or remove a star3★−0.3 vs PA avg
- Quality measuresCan add or remove a star2★−1.5 vs PA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 46% of peersPA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 27% of peersPA avg3.3★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 6% of peersPA avg3.5★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.75hrsAbove 57% of peersPA avg3.89Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.72hrsAbove 57% of peersPA avg0.78Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better40%Above 68% of peersPA avg47%RN turnover71%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$8,190Above only 40% of peersPA avg$28,640Fines · denials1 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2023 – May 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
May 1, 2025Cycle 1worst E · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected May 20, 2025
- F656Develop 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 PlanningD · isolatedCorrected May 20, 2025
- F657Develop 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 PlanningD · isolatedCorrected May 20, 2025
Aug 8, 2024Cycle 2worst E · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Sep 10, 2024
- Ensure meals and snacks are served at times in accordance with residentâs 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.Nutrition and DietaryE · patternCorrected Sep 10, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Sep 10, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 10, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareE · patternCorrected Sep 10, 2024
- F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Sep 10, 2024
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationD · isolatedCorrected Sep 10, 2024
Mar 27, 2024Cycle 2worst E · no actual harm
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 26, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 9, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 23, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Apr 23, 2024
Sep 8, 2023Cycle 3worst F · no actual harm
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationD · isolatedCorrected Oct 3, 2023
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareE · patternCorrected Oct 3, 2023
- F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected Oct 3, 2023
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Oct 3, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 3, 2023
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Oct 3, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 3, 2023
- F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Oct 3, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Oct 3, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 3, 2023
Jun 6, 2023Cycle 3worst G · actual harm$8,190, payment denial
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Oct 3, 2023
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Aug 16, 2023
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsB · patternCorrected Aug 16, 2023
Feb 15, 2023Cycle 3worst D · no actual harm
- F656Develop 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 PlanningD · isolatedCorrected Mar 3, 2023
- F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected Mar 3, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.75hrs
- Registered nursesRN hours only0.72hrs
- Licensed practical nursesLPN hours1.01hrs
- Nurse aidesCNA hours2.01hrs
- Weekend nursingAll staff on Saturdays and Sundays3.38hrs
- Pennsylvania average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better40%Above 68% of peersPA avg 47%
- RN turnoverRegistered nurses only71%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy70 certified beds · ~61 residents a day87%Above only 48% of peersPA avg 82%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $8,190In fines
- 1Fine
- 1Payment denial
- $28,640PA avg in fines
Actions on record
- Jun 6, 2023Civil money penalty$8,190
- Jun 6, 2023Denial of payment for new admissionsfrom Sep 6, 2023
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- Pa Tenant 3 Holdings, LLC
- 2020 Gsr Dynasty LLC
- Eaz Operating Company, LLC
- George S. Repchick 2020 Family Dynasty Trust
- Help for the Kids, LLC
- Pa Tenant 3 Mezz Holdings, LLC
- Pa Tenant 3 Mezz, LLC
- Susan Keefer
- Michael Kelly
- Senior Health Care Solutions LLC
- Kaitlin Estell
- Michael Falco
- Kelly Fedorka
- Stepanie Hanrahan
- Kathleen Hentschel
- Susan Keefer
- Michael Kelly
- +6 more
- Oxford Finance LLC
- Oxford Finance LLC
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 396148 · 111 RIVERS EDGE DRIVE, MATAMORAS, PA, 18336.
- Percentiles compare this facility with every rated nursing home in Pennsylvania and Pike County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









