Twinbrook Healthcare and Rehabilitation Center

Name: Twinbrook Healthcare and Rehabilitation Center
Address: 3805 FIELD STREET, Erie, PA, 16511, US
Telephone: 8148985600

3805 Field Street, Erie, PA 16511 · Erie County · 118 certified beds · avg 101 residents/day · certified since Jan 1, 1967

Part of chain: POLLAK HOLDINGS (6 facilities, chain avg rating 1.6★)

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

0.00

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · 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.

All citations in the current public record (37)

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 16, 2026	E · Potential for harm, repeated	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Apr 16, 2026	E · Potential for harm, repeated	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Apr 16, 2026	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.
Apr 16, 2026	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.
Apr 16, 2026	D · Potential for harm, one-off	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.
Apr 16, 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.
Apr 16, 2026	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.
Apr 16, 2026	D · Potential for harm, one-off	The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit.
Apr 16, 2026	D · Potential for harm, one-off	The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
Apr 16, 2026	D · Potential for harm, one-off	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.
Mar 10, 2026	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. · from a complaint
Mar 10, 2026	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Feb 12, 2026	C · Minimal risk, facility-wide	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 12, 2026	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Jun 12, 2025	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Apr 25, 2025	F · Potential for harm, facility-wide	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.
Apr 25, 2025	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.
Apr 25, 2025	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Apr 25, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Apr 25, 2025	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Apr 25, 2025	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.
Apr 25, 2025	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.
Apr 25, 2025	D · Potential for harm, one-off	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Apr 25, 2025	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.
Apr 25, 2025	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Dec 23, 2024	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. · from a complaint
Dec 23, 2024	E · Potential for harm, repeated	The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint
Dec 23, 2024	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Oct 24, 2024	E · Potential for harm, repeated	The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint
May 17, 2024	E · Potential for harm, repeated	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.
May 17, 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.
May 17, 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.
May 17, 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.
May 17, 2024	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
May 17, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
May 17, 2024	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.
May 17, 2024	D · Potential for harm, one-off	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.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 10).

Year	Citations	Worst severity that year
2024	12	E
2025	11	F
2026	14	E

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)

No fines or payment denials in the published 3-year window.

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)	0.00	3.94	3.95	—
Registered Nurse hours	0.00	0.80	0.69	—
Weekend total nurse staffing	0.00	3.58	3.50	—
Weekend RN hours (not acuity-adjusted)	0.00	0.56	0.48	—
Total nursing staff turnover (%)	0.0	44.5	45.8	—
RN turnover (%)	0.0	39.9	42.9	—

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 0.00, RN 0.00, weekend 0.00. Staffing rating: —/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: 2/5 · long-stay residents: 3/5 · short-stay residents: 2/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Hersh, Deena	Individual	Direct Ownership Interest	NOT APPLICABLE	04/23/2021
Carter, Seth	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2025
Carter, Seth	Individual	ADP of the SNF	NOT APPLICABLE	12/18/2025
Marquetti, Elena	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2025
Marquetti, Elena	Individual	ADP of the SNF	NOT APPLICABLE	12/18/2025
Pollak, Elie	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/23/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How do you coordinate and monitor care for residents who receive dialysis?"
"How often does each resident's doctor visit and review their care in person?"
"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
Ball Pavilion, the	2.0 mi	Erie, PA	★★★★★	4/5
Pennsylvania Soldiers and Sailors Home	3.1 mi	Erie, PA	★★★★★	4/5
Nightingale Nursing and Rehab Center	3.1 mi	Erie, PA	★★★★☆	4/5
Lecom at Village Square, LLC	4.0 mi	Erie, PA	★★★★☆	4/5
Sarah Reed Senior Living	4.1 mi	Erie, PA	★★★★★	5/5
Lecom at Elmwood Gardens, LLC	5.4 mi	Erie, PA	★★★★★	5/5
Greenfield Healthcare and Rehabilitation Center	6.3 mi	Erie, PA	★☆☆☆☆	1/5	abuse
Millcreek Manor	6.5 mi	Erie, PA	★★★★☆	3/5
Lecom at Presque Isle, INC	6.7 mi	Erie, PA	★★★☆☆	3/5
Walnut Creek Nursing and Rehab	7.5 mi	Erie, PA	★★☆☆☆	2/5	abuse

Compare this facility with the 3 closest →

All facilities in Erie →

Facility data as of CMS processing date 2026-08-01. CCN 395041.

The Care File

Visit checklist — Twinbrook Healthcare and Rehabilitation Center

3805 Field Street, Erie, PA 16511 · 8148985600

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $0

Questions for the administrator:

☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How do you coordinate and monitor care for residents who receive dialysis?"
☐ "How often does each resident's doctor visit and review their care in person?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 395041 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)