MIFFLIN CENTER

500 EAST PHILADELPHIA AVENUE, SHILLINGTON, PA 19607 (610) 777-7841
For profit - Corporation 136 Beds GENESIS HEALTHCARE Data: November 2025
Trust Grade
68/100
#317 of 653 in PA
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Last Inspection: November 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Mifflin Center in Shillington, Pennsylvania, has a Trust Grade of C+, indicating that it is slightly above average but not exceptional. It ranks #317 out of 653 facilities statewide, placing it in the top half of Pennsylvania options, and #11 of 15 in Berks County, meaning only a few local facilities are better. The facility is improving, with issues decreasing from 8 in 2023 to 3 in 2024. Staffing is rated average, with a turnover rate of 28%, which is good compared to the state average of 46%, suggesting that staff are relatively stable. Notably, there have been no fines, which is a positive sign. However, there are concerns regarding food safety and care planning. Recent inspections revealed that food was not served or stored properly, including instances of staff not changing gloves or practicing hand hygiene, which could increase the risk of contamination. Additionally, the facility failed to implement care plans for some residents, leaving them without necessary protections, such as protective sleeves for skin care. While Mifflin Center has strengths, such as stable staffing and no fines, families should be aware of these weaknesses related to health and safety practices.

Trust Score
C+
68/100
In Pennsylvania
#317/653
Top 48%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
8 → 3 violations
Staff Stability
✓ Good
28% annual turnover. Excellent stability, 20 points below Pennsylvania's 48% average. Staff who stay learn residents' needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Skilled Nurses
○ Average
Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
17 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 3 issues

The Good

  • Low Staff Turnover (28%) · Staff stability means consistent care
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover is low (28%)

    20 points below Pennsylvania average of 48%

Facility shows strength in staff retention, fire safety.

The Bad

3-Star Overall Rating

Near Pennsylvania average (3.0)

Meets federal standards, typical of most facilities

Chain: GENESIS HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 17 deficiencies on record

Nov 2024 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop or implement a compre...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop or implement a comprehensive care plan and/or interventions that addressed individual resident needs as identified in the comprehensive assessment for three of 27 sampled residents. (Resident's 15, 17, 21) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included malignant neoplasm of prostate and Alzheimer's disease. Review of the current care plan revealed Resident 15 was at risk for skin breakdown with an intervention for staff to apply Geri-Sleeves (sleeves to protect skin from damage caused by friction and shearing) to bilateral arms in the morning and remove during provision of care. Multiple observations on November 12, 13, and 14, 2024, between 9:30 a.m. and 1:45 p.m., revealed Resident 15 sitting in a wheelchair, in the day room, shirt sleeves pushed up, and Geri-Sleeves not applied. Clinical record review revealed that Resident 17 was admitted to the facility on [DATE], and had diagnoses that included Parkinson's disease, multiple sclerosis, and metabolic encephalopathy. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated October 10, 2024, noted that the resident's activities, dehydration/fluid maintenance, nutritional status, pain, pressure ulcer/injury, and psychosocial well-being were to be addressed in the care plan. There was no evidence that interventions to address Resident 17's activities, dehydration/fluid maintenance, nutritional status, pain, pressure ulcer/injury, and psychosocial well-being were included in the current care plan. Clinical record review revealed that Resident 21 had diagnoses that included polyneuropathy and muscle weakness. Review of the current care plan revealed Resident 21 demonstrated loss of range of motion in bilateral lower extremities and was at risk for functional deterioration with an intervention for restorative range of motion. There was no evidence that interventions were developed or implemented to address Resident's 21's risk for functional deterioration. In an interview on November 15, 2024, at 9:40 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the residents' current care plans. CFR 483.21(b)(1) Comprehensive Care Plans Previously cited 12/7/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

Based on facility documentation, resident interview, results of a test tray, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing tem...

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Based on facility documentation, resident interview, results of a test tray, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature in the main dining room. Findings include: Review of the facility policy entitled, Dining Service Operations: Test Trays, last reviewed April 8, 2024, revealed that food would be palatable, attractive, and served at a safe and appetizing temperature. Review of Dining Council Minutes from September 30, 2024, and October 6 and 14, 2024, revealed that residents had stated that their food gets served cold and was not palatable. In a group interview on November 13, 2024, at 10:30 a.m., Residents 54 and 62 reported that food served in the main dining room was often served cold and not palatable. Results of a test tray audit conducted on November 13, 2024, at 11:33 a.m., after the last resident meal tray was served in the main dining room from the main kitchen, revealed a smothered chicken breast was served at a temperature of 110.0 degrees Fahrenheit, mashed potatoes at 115.1 degrees Fahrenheit, and ravioli pasta at 124.0 degrees Fahrenheit. All food items were cool to taste. In an interview during this observation period, the Dietary Director stated that the hot food should have achieved a temperature of 135 degrees Fahrenheit or higher. 28 Pa. Code 201.14(a) Responsibility of licensee.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on policy review and observation, it was determined that the facility failed to properly serve food and maintain sanitary conditions in the main kitchen. Findings include: Review of the facility...

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Based on policy review and observation, it was determined that the facility failed to properly serve food and maintain sanitary conditions in the main kitchen. Findings include: Review of the facility policy entitled, Food: Preparation, last reviewed April 8, 2024, revealed that all staff were to practice proper hand hygiene and glove use. Dining Services staff were responsible for food preparation procedures and using serving utensils appropriately to prevent cross contamination. Observation of the tray line service on November 13, 2024, at 11:00 a.m., revealed the following: Dietary Employee 1 (DE 1) was wearing gloves and operating the tray line. DE 1 grabbed a smothered chicken breast without a serving utensil. DE 1 then walked away from the tray line to open a bag of hot dog buns, she then opened and closed a drawer of utensils, and wiped food substance off her apron without changing gloves or performing hand hygiene between each task. DE 1 then placed a small metal container of food from the steam table directly top of the cooked meat. CFR 483.60(i) Food Safety Requirement Previously cited 12/7/23 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(2.1) Management.
Dec 2023 8 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents on on...

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Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents on one of four nursing units (400 unit). (Residents 3, 20, 117) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included stroke, dementia, and right-sided hemiplegia (paralysis of the right side of the body). Review of the Minimum Data Set (MDS) assessment, dated November 2, 2023, revealed that the resident had cognitive impairment and required assistance from staff with eating. On December 5, 2023, from 12:20 p.m. through 12:38 p.m., Licensed Practical Nurse (LPN) 1 was observed standing to assist Resident 3 with lunch while the resident was seated in the wheel chair. Clinical record review revealed that Resident 20 had diagnoses that included dementia and diabetes. Review of the MDS assessment, dated November 8, 2023, revealed that the resident had cognitive impairment and required assistance from staff with eating. On December 5, 2023, from 12:31 p.m. through 12:43 p.m., Nurse Aide (NA) 1 was observed standing to assist Resident 20 with lunch while the resident was seated in the wheel chair. Clinical record review revealed that Resident 117 had diagnoses that included Alzheimer's Disease, protein calorie malnutrition, and anxiety. Review of the MDS assessment, dated November 16, 2023, revealed the resident had cognitive impairment, and required supervision of staff while eating. On December 5, 2023, at 12:16 p.m., Resident 117 was observed in the dining room seated next to Resident 74. Resident 117 was observed pulling Resident 74's tray towards her and grabbing an open applesauce cup off of the resident's tray. Resident 117 took a straw and proceeded to eat the applesauce with the edge of the straw. At no time did staff redirect the resident. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was complete to accurately reflect the resident's status for four of 27 sampled residents. (Residents 24, 89, 111, 128) Findings include: Clinical record review revealed that Section D (Mood) of Resident 24's MDS assessment dated [DATE], was incomplete. Clinical record review revealed that Section D (Mood) of Resident 89's MDS assessment dated [DATE], was incomplete. Clinical record review revealed that Section I (Active Diagnoses) of Resident 111's MDS assessment dated [DATE], inaccurately indicated that Resident 111 did not have depression. Section N (Medications) indicated Resident 111 had received antidepressant medication. Further review of the clinical record revealed Resident 111 was admitted to the facility October 23, 2023. The physician noted at this time that Resident 111 had a diagnosis of depression and antidepressant medications were ordered. In an interview on December 7, 2023, at 10:40 a.m., the Director of Nursing confirmed that Resident 111 had the diagnosis of depression since admission to the facility and it was not noted on the MDS. Clinical record review revealed that Section N (Medications) of Resident 128's MDS assessment dated [DATE], inaccurately indicated that the resident was not on an antipsychotic medication during the seven-day review period, however review of the rresident's record revealed the resident did receive an antipsychotic (paliperidone) during the seven-day review period. In an interview on December 7, 2023, at 10:00 a.m., the Director of Nursing confirmed that Resident 128 had received an antipsychotic during the review period and it was not noted on the MDS. CFR 483.20(g) Accuracy of Assessments Previously Cited 12/1/22
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for five of 27 sampled residents. (Residents 76, 111, 119, 134, 135) Findings include: Clinical record review revealed that Resident 76 was admitted to the facility on [DATE], and had diagnoses that included diabetes mellitus and hypertension (high blood pressure). The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated November 9, 2023, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 76's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 111 was admitted to the facility on [DATE], and had diagnoses that included depression and diabetes mellitus. The MDS CAA summary dated October 30, 2023, noted that the resident's urinary incontinence and psychotropic drug use were to be addressed in the care plan. There was no evidence that interventions to address Resident's 111 urinary incontinence and psychotropic drug use were included in the current care plan. Clinical record review revealed that Resident 119 was admitted to the facility on [DATE], and had diagnoses that included hypertension (high blood pressure) and depression. The MDS CAA summary dated November 11, 2023, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 119's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 134 was admitted to the facility on [DATE], and had diagnoses that included depression and chronic kidney disease. The MDS CAA summary dated November 19, 2023, noted that the resident's urinary incontinence and psychotropic drug use were to be addressed in the care plan. There was no evidence that interventions to address Resident 134's urinary incontinence and psychotropic drug use were included in the current care plan. Clinical record review revealed that Resident 135 was admitted to the facility on [DATE], and had diagnoses that included hypertension (high blood pressure) and a disorder of the bladder. The MDS CAA summary dated November 22, 2023, noted that the resident's urinary incontinence and visual function were to be addressed in the care plan. There was no evidence that interventions to address Resident 135's urinary incontinence and visual function were addressed in the current care plan. In an interview on December 7, 2023, at 9:40 a.m., the Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in the residents' current care plans. 28 Pa. Code 211.12(d)(1)(5)Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and interview, it was determined that the facility failed to provide services to m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for residents unable to carry out activities of daily living for four of 27 sampled residents. (Residents 9, 26, 32, 61) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included hemiplegia (severe or complete loss of motor function on one side of the body) and traumatic brain injury. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and required extensive staff assistance for personal hygiene. The care plan identified that Resident 9 had difficulty caring for himself due to his physical limitations and interventions included that staff assist with daily hygiene and grooming. Observations on December 5, 2023, at 11:38 a.m., and December 6, 2023, at 10:21 a.m., revealed that Resident 9's fingernails on both hands were long and jagged. Clinical record review revealed that Resident 26 had diagnoses that included peripheral vascular disease and polyneuropathy (damage to peripheral nerves). The MDS assessment dated [DATE], indicated that the resident was oriented and required extensive staff assistance for personal hygiene. The care plan identified that Resident 26 had difficulty caring for himself due to his physical limitations and interventions included that staff assist with daily hygiene and grooming. Observations on December 5, 2023, at 11:44 a.m., and December 6, 2023, at 9:35 a.m., revealed that Resident 26's fingernails on both hands were long and jagged with dirt underneath. In an interview at that time the resident stated that he preferred his nails to be kept short. Resident 26 could not recall the last time staff provided or offered nail care. Clinical record review revealed that Resident 32 had diagnoses that included a stroke and hemiplegia. The MDS assessment dated [DATE], indicated that the resident had moderate impaired cognition, usually understood others, could expressed herself sometimes, and required extensive staff assistance for personal hygiene. The care plan identified that Resident 32 had physical limitations and required staff assistance for daily hygiene and grooming. Observations on December 6, 2023, at 12:35 p.m., and on December 7, 2023, at 12:50 p.m., revealed that Resident 32's fingernails on both hands were long, jagged, and yellow. In an interview Resident 32 stated, I wish I could get these trimmed, and I don't like them like this. Clinical record review revealed that Resident 61 had diagnoses that included stroke, hemiplegia, bilateral hand contractures, and lack of coordination. The MDS assessment dated [DATE], indicated that the resident was oriented and required extensive assistance for daily hygiene and grooming. The care plan identified that Resident 61 had physical limitations and required staff assistance for daily hygiene and grooming. Observations on December 5, 2023, at 11:40 a.m., and December 6, 2023, at 12:15 p.m., revealed that Resident 61's fingernails on both hands were long and jagged, and the right palm had scratch marks and circular indentations from the fingers. Observations on December 7, 2023, at 12:40 p.m., revealed the resident's nails were short and an abrasion was present on the side of the finger. In an interview on December 5, 2023, at 11:40 a.m., the resident stated that self trimming of the nails was difficult. In an interview on December 7, 2023, at 12:40 p.m., the resident revealed that she had chewed off and filed down her nails by herself. In an interview on December 6, 2023, at 2:10 p.m., the Director of Nursing stated that nails were to be done on resident shower days as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for two of 27 sampled residents. ...

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Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for two of 27 sampled residents. (Resident4, 238) Findings include: Review of the policy entitled, General Dose Preparation and Medication Administration, last reviewed April 24, 2023, revealed staff were to obtain vital signs if necessary, and document necessary medication administration information. Clinical record review revealed that Resident 4 had diagnoses that included hypertension (high blood pressure). A physician's order dated November 14, 2023, directed staff to administer a medication (metoprolol succinate) once a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 180 millimeters of mercury (mm/Hg). Review of Resident 4's medication administration records (MAR) revealed that staff administered the medication 17 times in November and six times in December 2023 when the resident's SBP was less than 180 mm/Hg. In an interview on December 7, 2023, at 9:50 a.m., the Director of Nursing (DON) confirmed that the medications were administered outside established parameters for Resident 4. Clinical record review revealed that Resident 238 had diagnoses that included hypertension. On November 25, 2023, the physician ordered staff to administer a blood pressure medicine (metoprolol tartrate) twice a day. Staff were not to administer the medication if the resident's SBP was less than 90 mm/Hg or if the heart rate (the number of times a heart beats in one minute) was less than 60. Review of Resident 238's November and December 2023 MARs revealed that staff administered the medication 22 times with no documentation that the blood pressure and heart rate was assessed prior to medication administration per physician's order. In an interview on December 7, 2023, at 1:20 p.m., the DON confirmed there was documented evidence that the blood pressure and heart rate were taken prior to medication administration per physician's order. CFR 483.25 Quality of Care Previously cited 12/1/22 28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to provide proper catheter care to prevent the risk of infection for two of four sa...

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Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to provide proper catheter care to prevent the risk of infection for two of four sampled residents who utilized an indwelling urinary catheter (a flexible tube that drains urine from the bladder). (Resident 32, 54) Findings include: Review of the facility policy entitled, Catheter: Indwelling Urinary last reviewed April 2023, revealed that a urinary catheter system should be inspected to ensure connections are secure, the tubing should be kept off the floor, and the emptying spigot of the Foley catheter bag system should not be in contact with non-sterile surfaces. Clinical record review revealed that Resident 32 had diagnoses that included neuromuscular dysfunction of the bladder and a history of a stroke with residual left-sided upper and lower extremity weakness. According to the Minimum Data Set (MDS) assessment, dated August 24, 2023, the resident had an indwelling urinary catheter in place. On December 6, 2023, from 12:35 p.m. until 1:03 p.m., Resident 32 was observed in a wheelchair in front of the 300 unit nurse's station. The tubing of the urinary catheter was wrapped around the front right wheel of the wheelchair, touching the floor. Resident 32 was moving the wheelchair repeatedly rolling over the catheter tubing. The Director of Nursing, LPN2, and NA2, walked by and engaged in conversation with Resident 32 and none of them attempted to adjust the catheter tubing. At 1:03 p.m., the resident was moved into the dayroom and the catheter tubing was still in contact with the floor. On December 7, 2023, from 12:48 p.m. until 12:54 p.m., Resident 32 was observed sitting in front of the 300 unit nurse's station with catheter tubing on the floor. LPN2 was present, but did not attempt to secure the tubing. Clinical record review revealed that Resident 54 had diagnoses that included neuromuscular bladder dysfunction and paraplegia. According to the MDS assessment, dated August 30, 2023, the resident had an indwelling catheter in place. A physician's order dated July 13, 2023, directed staff to perform indwelling catheter care every shift and as needed. On December 5, 2023, from 10:55 a.m. until 1:15 p.m., Resident 54 was observed lying in bed with the catheter tubing draining into a large urine collection bag hung on the bedframe. The draining spigot of the collection bag, used to empty urine out of the bag, was unlatched from the secure holder. From 10:15 a.m. until 12:49 p.m., the spigot was in direct contact with the bed. From 12:49 p.m. until 1:15 p.m., the bed was raised by Resident 54, the spigot remained unsecured and was hanging from the Foley bag. The unlatched spigot was visible when looking at the resident from the hallway. LPN2 walked by the resident's room and did not attempt to secure the spigot. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on one...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on one of four nursing units. (400 unit) Findings include: Observations throughout the unit December 5, 2023, at 10:00 a.m. through December 6, 2023, 1:00 p.m., revealed the following: In room [ROOM NUMBER] bed C, the paint was peeling and marred. Bed D overbed table had dried liquid and food debris on the base. The HVAC vents at beds A and B were dusty and dirty. At bed C, the front of the bedside cabinet had exposed compressed board and there were gaps around the door. The wall next to the bed was marred. The bathroom intake air vent had a build up of thick dust and the walls and door were marred. The fall mat in room [ROOM NUMBER] bed B was littered with smashed food crumbs. Bed D had no light cover on the overbed light and the bedside cabinet had gaps around the door. The bathroom had no toilet paper holder and the paint was peeling on the wall. In room [ROOM NUMBER] bed A, the bedside cabinet door hinge was broken. The wall beside bed B was marred. An IV pole between bed B and D contained an empty IV bag and tubing and the pole had dried liquid at the base. In the bathroom there was no toilet paper holder and the walls and door were marred. There was a hole in the bathroom wall in room [ROOM NUMBER]. The bathroom door and wall were marred in room [ROOM NUMBER]. In room [ROOM NUMBER], next to bed A, food debris and dried liquid were observed on the floor. The bedside cabinet had cobwebs at the base. Bed B, C, D the bedside cabinet had gaps around the doors and bed D door had no handle. The bathroom wall was marred and scuffed. In room [ROOM NUMBER] bed A, there was a discarded nasal cannula and tubing laying on the floor next to the bedside cabinet. On top of the fall mat next to bed B, there was a torn piece of a brief. On the floor under the head of the bed C, there was black dirt. There was thick dust on the back of the television between beds B and D. There was dust, cobwebs, and black dirt under the head of bed of bed D. In the bathroom there was no toilet paper holder, the length of the front of the sink had exposed press board, and the door and walls were marred and scuffed. In room [ROOM NUMBER] bed C, the overbed table had food debris and dried liquid spillage. There was dust and dirt at the head of the bed on the floor. Bed D had dried liquid spillage, dust, and dirt under the head of the bed on the floor. In the bathroom, there was no toilet paper holder, the walls were marred, there were cobwebs near the floor under the sink, and a square hole in the ceiling with exposed pipes. In room [ROOM NUMBER] bed A, the overbed table had dried paper napkin remnants stuck to the surface and dried liquid spillage. The bedside cabinet for bed B had cobwebs at the bottom. The overbed table for bed C had dried liquid and food particles. The wall was marred and missing paint. There was an oxygen concentrator with a nasal cannula that was dusty and laying on the floor by bed D. In the bathroom there was no toilet paper holder. There were cobwebs on the walls that contained debris. The window curtains in rooms 402, 406, 408, 414, 416, and 418 were torn and and pulled out from the track. In the hallway across from the soiled utility room, the light covers were full of debris. The hand rail outside room [ROOM NUMBER] was missing the end. In the hallway across from rooms [ROOM NUMBERS], debris was observed between the windows and screens. CFR 483.90(i) Safe/Functional/Sanitary/Comfortable Environment Previously Cited 12/1/22 28 Pa. Code 201.18(b)(3) Management.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of four nursing un...

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Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of four nursing units. (Cherry Tree Lane) Findings include: Observations during the kitchen tour on December 5, 2023, at 10:00 a.m., revealed that inside the Ice Cream Freezer, there were multiple areas of dried food debris on the wall and on the bottom. There was a leaf on the bottom of the freezer. There were two utensil drawers containing clean utensils. One drawer had a food scoop with dried food debris in it. The other drawer had dried food debris in it. When that drawer was open, there was long strand of hair sticking out from the inside track of the drawer, close to the clean utensils. On the pot and pan rack, there was a long strand of hair where the clean items were stored. Review of the facility's policy entitled, Safe Handling for Foods from Visitors, last reviewed April 24, 2023, revealed when food was brought into the facility for the residents by visitors that staff should label foods with the resident's name. Observation of the Cherry Tree Lane unit pantry on December 6, 2023, at 11:45 a.m., revealed five bottles of opened salad dressing and four containers of Gatorade, milk, soda, and juice that were not labeled with a resident's name. The inside of the microwave was rusted and damaged. In an interview on December 6, 2023, at 12:40 p.m., the Administrator confirmed the microwave and refrigerator were used for the residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(2.1) Management.
Dec 2022 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to complete assessments to accur...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to complete assessments to accurately reflect the resident's status for two of 32 sampled residents. (Residents 45, 128) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included obesity, and hemiplegia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed staff failed to accurately document that the resident had a skin condition, moisture associated skin damage (MASD) which included incontinence associated dermatitis (IAD) during the review period. Review of a skin assessment dated [DATE], revealed that Resident 45 had MASD on the sacrum. In an interview on December 1, 2022, at 11:00 a.m., the Administrator confirmed that the MDS assessment was inaccurate. Clinical record review revealed that in Resident 128's MDS assessment dated [DATE], the Brief Interview for Mental Status (BIMS) assessment of the resident's cognitive patterns in Section C was incomplete. The Mood Interview assessment in Section D was incomplete. The Potential Indicators of Psychosis in Section E was incomplete.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to review and revise the care pl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to review and revise the care plan for two of 32 sampled residents. (Resident 41, 71) Findings include: Clinical record review revealed that Resident 41 had diagnoses that included anxiety and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident received an antipsychotic medication four of seven days in the review period. A physician order dated October 8, 2022, directed staff to administer Quetiapine (an antipsychotic medication) 12.5 milligrams at bedtime. Review of the care area assessment (CAA) dated October 14, 2022, revealed that the use of antipsychotic medication would be addressed on the resident's care plan. Resident 41's care plan was not updated to include the use of an antipsychotic medication. Clinical record review revealed that Resident 71 had diagnoses that included overactive bladder. Review of the MDS assessments dated August 25, 2022, and November 25, 2022, revealed that the resident utilized an indwelling catheter. Review of the CAA dated August 25, 2022, revealed that the use of a urinary catheter would be addressed on the resident's care plan. Resident 71's care plan was not updated to include the use of a urinary catheter. In an interview on December 1, 2022, at 12:16 p.m., the Administrator stated that Resident 41's care plan was not revised to include the use of an antipsychotic medication and Resident 71's care plan was not revised to include the use of a urinary catheter. 28 Pa. Code 211.11(d) Resident care plan.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's ord...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for one of 32 sampled residents. (Resident 43) Findings include: Clinical record review revealed that Resident 43 was admitted on [DATE], with diagnoses that included constipation. A physician's order dated March 7, 2022, directed staff to administer 30 milliliters of Milk of Magnesia at bedtime, if no bowel movement in three days. Review of bowel movement tracking documentation for Resident 43 revealed that the there was no bowel movements recorded from November 14, 2022, through November 18, 2022, and from November 22, 2022, through November 30, 2022. Review of the Medication Administration Record for November 2022, revealed that the resident was not provided the Milk of Magnesia as ordered. In an interview on December 1, 2022, at 10:03 a.m., the Director of Nursing confirmed there was no documentation to support that the physician's order was followed. 483.25 Quality of care previously cited 5/13/22, 11/18/21 28 Pa. Code 211.12(d)(1)(5)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on clinical record review and resident and staff interview, it was determined that the facility failed to timely assess nutritional status for two of seven sampled residents at nutrition risk. (...

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Based on clinical record review and resident and staff interview, it was determined that the facility failed to timely assess nutritional status for two of seven sampled residents at nutrition risk. (Residents 41, 126). Findings include: Clinical record review revealed that Resident 41 had diagnoses that included muscle weakness, chronic obstructive pulmonary disease, anxiety, and Alzheimer's disease. Review of the care plan revealed that the resident was at nutrition risk. In an interview on November 28, 2022, at 12:30 p.m., the resident stated that he had a poor appetite and believes he has lost weight. On October 9, 2022, the resident weighed 228 pounds (lbs.). On October 28, 2022, the resident weighed 194 lbs., reflecting a weight loss of 14.9 percent. There was no evidence that the dietitian assessed the resident's significant weight loss until November 15, 2022. Clinical record review revealed that Resident 126 had diagnoses that included cerebral infarction, hemiplegia, aphasia, Parkinson's disease, depression, anxiety, and type two diabetes mellitus. Review of the care plan revealed that the resident was at nutrition risk. On September 26, 2022, the resident weighed 190 lbs. On October 4, 2022, the resident weighed 174 lbs., reflecting a weight loss of 8.4 percent. There was no evidence that the dietitian assessed the resident's significant weight loss until October 18, 2022. In an interview on December 1, 2022, at 10:44 a.m., the regional Registered Dietitian stated that significant weight loss should be addressed within one week and there was no evidence that the residents significant weight loss was addressed within that timeframe. CFR 483.25(g)(1) Maintain acceptable parameters of nutritional status previously cited 5/13/22, 11/18/21 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review and staff interview, it was determined that the facility failed to offer non-phar...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review and staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of an as needed pain medication for one of one residents sampled who were on a pain management program. (Resident 81) Findings include: Review of the facility policy entitled, Pain Management, dated October 22, 2022, revealed that non-pharmacological interventions were to be attempted prior to the administration of as needed pain medications. Clinical record review revealed that Resident 81 was admitted to the facility on [DATE], with diagnoses that included fracture of the right leg. A Minimum Data Set assessment dated [DATE], revealed the resident had memory impairment, required extensive assistance from staff to complete activities of daily living, and experienced frequent pain in the last seven days. On October 31, 2022, a physician ordered for staff to administer an as needed pain medication (Tramadol) every six hours. Review of the Medication Administration Record for November 2022 revealed that staff had administered the as needed Tramadol medication a total of eight times. There was no documented evidence that staff had offered non-pharmacological interventions prior to the administration of the as needed pain medication. In an interview on December 1, 2022, at 10:21 a.m., the Director of Nursing confirmed that there was no documented evidence that staff had offered non-pharmacological interventions prior to the administration of the as needed pain medication as per facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
MINOR (C)

Minor Issue - procedural, no safety impact

Safe Environment (Tag F0921)

Minor procedural issue · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a comfortable, sanitary environment on three of four...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a comfortable, sanitary environment on three of four nursing units. (Nursing units 100, 300 and 400) Findings include: Observation throughout the facility during all days of the survey revealed the following: In the hall between rooms [ROOM NUMBERS], the wall paper boarder was ripped off the wall. At the head of the bed in room [ROOM NUMBER], there were exposed wires with no covers and the left window screen was out of the window. There was a large section of ripped wall paper in the hallway, outside of room [ROOM NUMBER]. In room [ROOM NUMBER], there were small particles of black debris on the floor of the resident's closet. The resident's over bed light did not work. The walls across from the nursing station above the handrails near room [ROOM NUMBER] were scratched and marred. There was missing wall paper in the smaller dining room. The walls in the bathrooms of resident rooms [ROOM NUMBER] were marred and scratched. 28 Pa Code 207.2(a) Administrator's responsibility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
  • • 28% annual turnover. Excellent stability, 20 points below Pennsylvania's 48% average. Staff who stay learn residents' needs.
Concerns
  • • 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.

About This Facility

What is Mifflin Center's CMS Rating?

CMS assigns MIFFLIN CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Mifflin Center Staffed?

CMS rates MIFFLIN CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 28%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Mifflin Center?

State health inspectors documented 17 deficiencies at MIFFLIN CENTER during 2022 to 2024. These included: 16 with potential for harm and 1 minor or isolated issues.

Who Owns and Operates Mifflin Center?

MIFFLIN CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 136 certified beds and approximately 127 residents (about 93% occupancy), it is a mid-sized facility located in SHILLINGTON, Pennsylvania.

How Does Mifflin Center Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, MIFFLIN CENTER's overall rating (3 stars) matches the state average, staff turnover (28%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Mifflin Center?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Mifflin Center Safe?

Based on CMS inspection data, MIFFLIN CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Mifflin Center Stick Around?

Staff at MIFFLIN CENTER tend to stick around. With a turnover rate of 28%, the facility is 18 percentage points below the Pennsylvania average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was Mifflin Center Ever Fined?

MIFFLIN CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Mifflin Center on Any Federal Watch List?

MIFFLIN CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

MIFFLIN CENTER

500 EAST PHILADELPHIA AVENUE, SHILLINGTON, PA 19607 | (610) 777-7841

C+
Trust Grade (68/100)
3.0
CMS Rating
17
Deficiencies

Strengths

  • Low turnover (28%)

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025