Oak Hill Center for Rehabilitation and Nursing
1020 North Union Street, Middletown, PA 17057 · Dauphin County · 136 certified beds · avg 128 residents/day · certified since Dec 1, 1976
Part of chain: MORDECHAI WEISZ (7 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 11, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 4, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 13, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 4, 2025 · F-0805 · triggered by a complaint
The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 30, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 25, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 8, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 30, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 8, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 30, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (60)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 7, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Sep 11, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 4, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 4, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 4, 2025 | ▲ G · Actual harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
| Apr 24, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Oct 30, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 8, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 8, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings. · from a complaint |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 25, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (15 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | D |
| 2024 | 42 | 3 | G ▲ |
| 2025 | 14 | 3 | G ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $61,932.
| Date | Type | Amount / length |
|---|---|---|
| Oct 30, 2024 | Fine | $44,777 |
| Apr 8, 2024 | Fine | $8,167 |
| Apr 8, 2024 | Fine | $8,988 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.19 | 3.94 | 3.95 | bottom 21% in Pennsylvania; bottom 21% in the U.S. |
| Registered Nurse hours | 0.42 | 0.80 | 0.69 | bottom 13% in Pennsylvania; bottom 26% in the U.S. |
| Weekend total nurse staffing | 2.98 | 3.58 | 3.50 | bottom 27% in Pennsylvania; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.41 | 0.56 | 0.48 | bottom 46% in Pennsylvania; top 47% in the U.S. |
| Total nursing staff turnover (%) | 58.8 | 44.5 | 45.8 | bottom 13% in Pennsylvania; bottom 18% in the U.S. |
| RN turnover (%) | 73.7 | 39.9 | 42.9 | bottom 5% in Pennsylvania; bottom 9% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.26, RN 0.43, weekend 3.04. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 1020 N Union Street LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2021 |
| Ahmad, Ayesha | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2021 |
| Ahmad, Ayesha | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2021 |
| Ahmad, Ayesha | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2021 |
| Lions Healthcare Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/07/2024 |
| Lions Healthcare Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/07/2024 |
| Popular Bank | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/01/2021 |
| Smith, Robert | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/02/2023 |
| Smith, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/02/2023 |
| Smith, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 01/02/2023 |
| Weisz, Mordechai | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/07/2024 |
| Weisz, Mordechai | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/07/2024 |
| Weisz, Mordechai | Individual | ADP of the SNF | NOT APPLICABLE | 11/07/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Courtyard Gardens Nursing and Rehab Ctr | 1.0 mi | Middletown, PA | ★★★★☆ | 4/5 | |
| Spring Creek Rehabilitation and Nursing Center | 6.6 mi | Harrisburg, PA | ★★☆☆☆ | 2/5 | |
| River's Bend Health & Rehab Center | 6.7 mi | Harrisburg, PA | ★☆☆☆☆ | 1/5 | abuse |
| Emerald Nursing and Rehabilitation | 8.1 mi | Elizabethtown, PA | ★★☆☆☆ | 2/5 | |
| Masonic Village at Elizabethtown | 8.3 mi | Elizabethtown, PA | ★★★★★ | 5/5 | |
| Kadima Rehabilitation & Nursing at Campbelltown | 9.2 mi | Palmyra, PA | ★☆☆☆☆ | 1/5 | SFF |
| Homeland Center | 9.6 mi | Harrisburg, PA | ★★★★☆ | 4/5 | |
| Camp Hill Skilled Nursing and Rehabilitation Ctr | 9.7 mi | Camp Hill, PA | ★★☆☆☆ | 2/5 | abuse |
| Amoroso Healthcare and Rehabilitation Woodridge | 10.0 mi | Harrisburg, PA | ★☆☆☆☆ | 1/5 | |
| Elizabethtown Nursing and Rehabilitation | 10.1 mi | Elizabethtown, PA | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 395347.