Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Williamsport Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found the kitchen in unsanitary condition, with dirty equipment, floors, and food storage areas, and discovered that required cleaning logs had not been completed for several months. Interviews with dietary staff and the DON confirmed that cleaning schedules were not followed and documentation was missing, despite facility policy requiring comprehensive cleaning records.
Surveyors found that the facility did not provide palatable or properly heated food, with residents receiving repetitive meals and food served at incorrect temperatures. Several residents reported cold and unappetizing meals, and a test tray confirmed that both hot and cold items were not within required temperature ranges. The Dietary Manager acknowledged menu substitutions, insufficient caloric intake, and lack of insulated carts for meal delivery.
A resident with moderate cognitive impairment indicated a strong preference for daily morning showers, but was only scheduled for showers twice weekly in the evening. Despite documentation of these preferences and multiple refusals of the offered showers, there was no evidence that her preferences were reassessed or that the care plan was updated to reflect her wishes, resulting in a failure to support resident choice as required.
A resident's MDS assessment was inaccurately coded to indicate anticoagulant use during the look-back period, despite the MAR showing no such medication was administered at that time. The DON confirmed the resident was not on an anticoagulant during the relevant period, and the error was due to incorrect coding.
The facility did not consistently hold or document care plan meetings for two residents, both of whom were cognitively intact and could not recall attending such meetings, with records lacking evidence of required quarterly reviews. Additionally, a resident receiving long-term Macrobid for UTI prevention due to ESBL and recurrent UTIs did not have this therapy addressed in the care plan.
Two residents did not receive showers and shaving as scheduled or per their preferences, despite being dependent on staff for ADLs due to conditions such as hemiplegia and Parkinson's disease. Documentation showed that scheduled showers were frequently missed without evidence of resident refusal, and observations confirmed ongoing issues with grooming and hygiene. Staff interviews revealed uncertainty about grooming routines, and facility policies lacked specific guidance on shower administration.
Staff failed to follow medication administration and disposal protocols for two residents. In one case, a resident was found with multiple pills left at the bedside, contrary to facility policy. In another, an LPN disposed of refused medications in a sharps container instead of the required Drug Buster disposal system. Interviews confirmed that these actions did not align with established procedures.
A resident with a stress fracture and chronic kidney disease requested PRN tizanidine for muscle spasms but was asked by an LPN to wait due to concerns about blood pressure and fall risk, despite being non-weight bearing and in a wheelchair. The resident received Xanax instead, and the LPN did not return to reassess or offer the tizanidine, resulting in increased pain and no further doses documented for that day.
An opened vial of tuberculin solution was found in a medication storage room refrigerator without a date of opening. Both an LPN and the DON confirmed that facility policy requires medications to be dated when opened, and the facility's policy document supports this requirement. This resulted in a deficiency related to proper medication labeling and storage.
A resident with a diabetic foot ulcer experienced improper placement of a wound vac, leading to maceration of the periwound area. The facility had the necessary supplies, but they were not the original brand, causing concern for the resident's wife. The DNS placed the wound vac and was responsible for staff education, but documentation of training was lacking. The DNS re-educated an LPN on proper placement, but this was not documented, resulting in a deficiency.
The facility failed to maintain safe hot water temperatures, with several residents reporting excessively hot water that could cause burns. The new Maintenance Supervisor confirmed the high temperatures but was initially unable to locate temperature logs or calibrate the thermometer. The facility lacked a policy for monitoring water temperatures, and logs for a specific period were missing.
The facility failed to ensure proper food handling and hand sanitization during meal service, affecting all 50 residents who ate meals from the kitchen. Staff were observed placing the ice scoop back into the ice bucket and using ice meant only to keep drinks cold. Additionally, a CNA did not sanitize her hands between assisting two residents with their meals and repositioning them.
The facility failed to ensure a resident was treated with dignity during a dining observation. The SLP was observed standing while assisting the resident with eating and drinking, contrary to the standard practice of sitting down. The resident has multiple diagnoses and requires assistance with daily activities, including eating. Both the DON and SLP acknowledged that staff should sit while assisting residents, in line with the facility's policy on Resident Rights.
The facility failed to conduct quarterly care plan meetings for a resident with moderate cognitive impairment and did not implement an oxygen care plan for another resident with hypoxemia, type 2 diabetes, and obstructive sleep apnea. The resident's oxygen was repeatedly set incorrectly, and staff were unsure of the correct settings.
The facility failed to ensure proper catheter care and placement for a resident, who was observed multiple times with his catheter bag in contact with the floor and other surfaces. Despite specific medical orders and facility policies, the catheter bag was not consistently secured, leading to repeated instances of improper placement.
The facility failed to provide proper respiratory care for two residents. One resident did not receive the prescribed oxygen level, and another resident's nebulizer treatment was not properly administered or assessed. Facility policies for oxygen concentrators and nebulizer treatments were not followed.
The facility failed to provide necessary mental health services to a resident with severe dementia, depression, and a psychotic disorder. Despite exhibiting significant behavioral issues, the resident did not receive timely psychiatric consultation, and there was inadequate documentation of family discussions regarding psychiatric services.
The facility failed to maintain a medication error rate below 5%, with errors including an LPN administering Creon by touching the capsule with an ungloved finger and another LPN administering insulin lispro without ensuring the resident received their meal within the recommended 15-minute window.
Failure to Maintain Kitchen Sanitation and Cleaning Documentation
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition and did not ensure that cleaning logs were completed and up to date. During an initial kitchen tour, surveyors observed that the convention oven burners had dark, charred particles caked on them, and the grill had food particles around its rim. The piping and wall behind the oven were dirty with old grease, and the kitchen floor had food crumbs and pieces of paper towel scattered throughout. The walk-in freezer also contained food crumbs and particles on the floor and shelving. No food was being cooked at the time of observation. Interviews with the Dietary Corporate Consultant and the Dietary Manager revealed that the kitchen cleaning logs for April, May, and June were blank and had not been completed. The Dietary Manager, who had recently started, acknowledged that cleaning tasks were not being consistently performed and that staff were not following a daily or deep cleaning schedule. The Director of Nursing confirmed awareness of the incomplete cleaning logs and noted recent management changes in the kitchen. The facility's policy required a comprehensive cleaning schedule and maintenance of cleaning logs, but these procedures were not followed.
Failure to Provide Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at safe and appetizing temperatures, as observed during multiple meal services. On one occasion, residents were served a chicken salad sandwich, beets, and pears instead of the scheduled menu of tomato basil soup, hot tuna and cheese sandwich, pickled beets, and sliced pears. Residents expressed dissatisfaction with the repetitive menu and questioned the frequent serving of chicken. The Dietary Manager was unable to explain the menu substitution and acknowledged that the meal provided did not meet adequate caloric intake. Staff interviews confirmed that soup was omitted from the meal due to unavailability, and the Dietary Manager noted ongoing concerns about menu repetition and the lack of a functioning food council. Multiple residents reported that food was often cold, repetitive, and unpalatable, whether eaten in the dining room or delivered to their rooms. The Dietary Manager acknowledged awareness of complaints about cold food and noted the absence of insulated food carts for tray delivery. A test tray revealed that hot food items were below the required temperature, and cold items were above the required temperature, with potato wedges noted as undercooked. The facility's policy requires hot foods to be held at or above 135°F and cold foods at or below 41°F, but these standards were not met during the survey.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
A resident with moderate cognitive impairment expressed a preference to shower every day and to have showers in the morning, which was documented during an interview and in her admission assessment. The resident's preferences were also recorded in a customary routines and activities observation, indicating it was very important for her to choose the type of bath and that she preferred to be bathed more than twice per week in the morning. Despite this, the resident was scheduled for showers only twice weekly on the evening shift, contrary to her stated preferences. Shower reports showed that the resident was offered showers on various dates, with several refusals, but there was no documentation that her preferences were reassessed or that the timing of the showers matched her morning preference. Progress notes did not indicate that the resident was offered a shower daily or that her preferences were revisited after refusals. The care plan did note her preference for daily showers, but this was not reflected in the actual shower schedule or in follow-up actions. Interviews with facility staff, including the DNS, confirmed that the resident's preferences should have been communicated and implemented, but this did not occur. The facility's policy required that resident preferences be identified and shared with the interdisciplinary team, but there was no evidence this process was followed in this case.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for one resident. A quarterly MDS assessment indicated that the resident received an anticoagulant medication during the look-back period. However, a review of the Medication Administration Record (MAR) for the same period showed no documentation that the resident received an anticoagulant. The Director of Nursing Services (DNS) confirmed that the resident was not on an anticoagulant during the look-back period, as it had been discontinued prior to that time. The MDS assessment was therefore coded in error, contrary to the requirements outlined in the CMS Resident Assessment Instrument (RAI) manual, which specifies that medication administration records should be reviewed for the 7-day look-back period to ensure accurate coding.
Failure to Document and Conduct Care Plan Meetings and Address Long-Term Antibiotic Use
Penalty
Summary
The facility failed to ensure that care plan meetings were held and properly documented for two residents, and did not develop a care plan for the long-term use of an antibiotic for another resident. One resident, who was cognitively intact, reported not remembering being invited to or attending care plan meetings regularly, and her record showed only two care plan meetings documented over a year, with no evidence of quarterly meetings as required. Another cognitively intact resident also did not recall having a care plan meeting, and her record lacked documentation of invitations being accepted or meetings being held, with only evidence that invitations were mailed. The Social Service Director confirmed that there was no documentation of responses to invitations or that meetings occurred. Additionally, a resident with a history of extended spectrum beta lactamase (ESBL) and recurrent urinary tract infections (UTIs) was prescribed long-term Macrobid therapy for UTI prevention. Despite this, the resident's comprehensive care plan did not include documentation addressing the long-term antibiotic use, nor the resident's history of UTIs and ESBL. The Director of Nursing Services acknowledged that a care plan should have been developed for the resident's long-term antibiotic use.
Failure to Provide Showers and Grooming per Resident Preference
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living (ADLs), specifically in administering showers and shaving, according to resident preferences for two residents. One resident, who was cognitively intact but required assistance due to hemiplegia and poor vision, reported not being regularly shaved or given scheduled showers. Documentation showed that out of 22 scheduled showers, only 10 were administered, with no record of the resident refusing care. Staff interviews revealed uncertainty about shaving frequency and reliance on shower days for shaving, while the Assistant Director of Nursing was unsure about the shaving schedule. Observations confirmed the resident had extensive facial hair and reported not being shaved as preferred. Another resident, dependent for all personal care due to Parkinson's disease and cognitive impairment, was observed multiple times with unshaven facial hair and brown debris under fingernails. Documentation indicated only 6 out of 22 scheduled showers were administered, again with no record of refusals. The facility's policies addressed AM care and fingernail cleaning but did not provide a specific policy for administering showers or bathing. The Director of Nursing confirmed the use of internal shower sheets, which were not retained as part of the medical record.
Failure to Follow Medication Administration and Disposal Protocols
Penalty
Summary
Facility staff failed to follow professional standards for medication administration and disposal for two residents. In one instance, a cognitively intact resident with multiple diagnoses, including COPD, alcoholic cirrhosis, diabetes, GERD, and heart failure, was found with two cups containing several pills left at her bedside. The resident reported that the nurse did not want to wake her and left the medications on her overbed table. The resident's care plan noted a history of rejecting and hiding medications. Interviews with nursing staff and the Director of Nursing confirmed that facility policy prohibits leaving medications at the bedside, and staff stated they do not leave medications with residents. In another instance, an LPN was observed disposing of non-narcotic medications refused by a resident into a sharps container rather than the designated Drug Buster disposal system, as required by facility policy. The LPN acknowledged the error during an interview. The DON provided the facility's medication pass procedure, which specifies that all wasted, dropped, or discarded medications must be disposed of in the Drug Buster disposal system. These actions demonstrate a failure to ensure medications were administered and disposed of according to professional standards.
Failure to Provide Timely PRN Pain Medication for Muscle Spasms
Penalty
Summary
A resident with a history of stress fracture of the right ankle and stage 3 chronic kidney disease requested a PRN dose of tizanidine for muscle spasms during the morning medication pass. The nurse, concerned about the risk of falls due to the medication's potential to lower blood pressure, asked the resident to wait until after lunch. The resident, who was non-weight bearing and used a wheelchair, expressed confusion about the fall risk but reluctantly agreed to wait and instead requested and received Xanax. The nurse did not return after lunch to check on the resident or offer the tizanidine, and the resident later reported increased spasms and pain, with observable signs of discomfort. Record review showed that the resident did not receive any further doses of tizanidine that day, and there was no documentation that the nurse followed up regarding the resident's need for the medication. The facility's pain management policy required pain medication to be given based on pain intensity and for the nurse to monitor the efficacy of pain management. The DON confirmed that the nurse should have followed up with the resident to see if the tizanidine was still needed, but this did not occur.
Failure to Date Opened Medication Vial in Storage Room
Penalty
Summary
Surveyors observed that in one of two medication storage rooms reviewed, an opened vial of tuberculin solution was found in the refrigerator without a date indicating when it was opened. During interviews, both an LPN and the Director of Nurses confirmed that facility policy requires medications to be dated when opened, especially when the medication has a shortened expiration date after opening. The facility's Medication Storage and Expiration policy, provided by the DON, also specifies that staff should record the date opened on the primary medication container. The failure to date the opened tuberculin solution constituted a deficiency in proper medication labeling and storage practices as required by facility policy and professional standards.
Improper Placement of Wound Vac Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper placement of a wound vacuum-assisted closure (vac) for a resident with a diabetic foot ulcer and other medical conditions, including acute osteomyelitis and type 2 diabetes. The resident's care plan required the use of a wound vac, and physician's orders specified the application and maintenance of the device. However, during a wound clinic visit, it was noted that the foam from the wound vac was improperly placed against the resident's skin, leading to maceration of the periwound area. The Medical Records Director acknowledged that the facility had all necessary supplies for the wound vac, although they were not the original brand, which concerned the resident's wife. The Director of Nursing Services (DNS) had placed the wound vac upon the resident's admission and was responsible for educating staff on its use. However, there was no specific documentation of education provided to the staff, and only one nurse was believed to have received training. The DNS checked the placement of the wound vac daily but was unsure if it had been placed improperly. The Executive Director was aware of the concerns regarding the supplies and the placement of the wound vac. The DNS re-educated a Licensed Practical Nurse (LPN) on proper placement following the concerns raised by the resident's wife, but this education was not documented. The facility's policy emphasized the importance of providing care consistent with professional standards to promote healing and prevent complications, but the improper placement of the wound vac foam led to a deficiency in the care provided to the resident.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure hot water temperatures were maintained within a safe range for five residents. During random observations, the water temperatures in the public bathroom and residents' sinks were found to be excessively high, reaching up to 134.4 degrees Fahrenheit. Several residents reported that the water was too hot to hold their hands under without burning their skin. The Maintenance Supervisor, who had just started, confirmed the high temperatures but was initially unable to locate temperature logs or calibrate the thermometer correctly. The Administrator acknowledged the issue and indicated that the water heater had been recently replaced. Further investigation revealed that the facility did not have a policy related to monitoring water temperatures or temperature guidelines. The Maintenance Supervisor later discovered that there were three hot water heaters in the building, each serving different resident wings. Temperature logs for the period between 4/23/24 and 5/9/24 were missing, and it was unclear how long the temperatures had been running high. The Administrator confirmed that no one had been checking the water temperatures after the former Maintenance Supervisor left until the new one started.
Failure to Ensure Proper Food Handling and Hand Sanitization
Penalty
Summary
The facility failed to ensure proper food handling and hand sanitization during meal service, which had the potential to affect all 50 residents who ate meals from the kitchen. During a dining observation, a CNA and the Housekeeping Supervisor were seen placing the ice scoop back into the ice bucket after use, which is against the facility's policy. Additionally, another CNA used ice from a container meant only to keep drinks cold, not for consumption. The Dietary Manager confirmed that staff had been educated on proper procedures, but the issue persisted. In another observation, a CNA failed to sanitize her hands between assisting two residents with their meals and repositioning them. This was observed during the noon meal service in the restorative dining room. Another CNA also failed to sanitize her hands before delivering a meal tray to a resident. The facility's Hand Hygiene Policy clearly states that hand sanitization should occur before and after resident contact, as well as after touching any resident belongings or environmental surfaces. Despite this policy, proper hand hygiene was not followed during the observed meal service.
Failure to Ensure Resident Dignity During Assistance with Eating
Penalty
Summary
The facility failed to ensure that Resident 4 was treated with dignity during a dining observation. The Speech Language Pathologist (SLP) was observed standing while assisting Resident 4 with eating and drinking, rather than sitting down, which is considered a more respectful and dignified approach. Resident 4 has multiple diagnoses, including paraplegia, lack of coordination, muscle contracture, abnormal posture, and mild cognitive impairment, and requires assistance with activities of daily living, including eating. During interviews, the Director of Nursing (DON) and the SLP both indicated that the standard practice is to sit while assisting residents with eating. The DON expressed that she hoped staff would sit in a chair while assisting residents, and the SLP confirmed that she usually sits down next to residents during evaluations. The facility's policy on Resident Rights, updated in 2017, emphasizes the right of residents to be treated with respect and dignity, including reasonable accommodation of their needs and preferences.
Failure to Conduct Quarterly Care Plan Meetings and Implement Oxygen Care Plan
Penalty
Summary
The facility failed to ensure care plan meetings were conducted quarterly for Resident 7 and did not implement an oxygen care plan for Resident 15. Resident 7, who had moderate cognitive impairment, indicated he did not remember attending a care plan meeting. His record showed only two care plan meetings in the past year, despite the requirement for quarterly meetings. The Social Service Director and the Director of Nursing confirmed the lack of quarterly care plan meetings for Resident 7. Resident 15, who had diagnoses including hypoxemia, type 2 diabetes mellitus with hyperglycemia, and obstructive sleep apnea, was observed multiple times with his oxygen meter set incorrectly at 2 liters instead of the prescribed 3 liters. The resident's record lacked a care plan for oxygen use, and staff were unsure of the correct oxygen settings. The Director of Nursing confirmed the oxygen should be set at 3 liters per nasal cannula, and the facility's policy required a comprehensive care plan, which was not followed for Resident 15.
Improper Catheter Care and Placement
Penalty
Summary
The facility failed to ensure proper catheter care and placement for Resident 15, who was observed multiple times with his catheter bag in contact with the floor and other surfaces. On several occasions, the catheter bag was seen touching the floor, the wheel of the wheelchair, and the resident's shoes. The dignity bag, meant to cover the urinary drainage bag, was not fully covering it, making the urine visible. Despite the resident's actions of pulling on the tubing and placing the bag in his lap, the staff did not consistently ensure the catheter bag was properly secured and off the floor until an LPN intervened briefly. The resident's medical records indicated a need for an indwelling urinary catheter due to a bladder/prostate mass, with specific orders to store the collection bag inside a protective dignity pouch and to ensure the tubing or any part of the drainage system did not touch the floor. The facility's policies on catheter care, including the use of a securement device and proper placement of the drainage bag, were not adhered to, as evidenced by the repeated observations of improper catheter bag placement. The Director of Nursing confirmed that the catheter bag and tubing should not touch the floor, yet this standard was not maintained for Resident 15.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in their treatment. Resident 15 was observed with a portable oxygen tank set at 2 liters per minute (LPM) instead of the prescribed 3 LPM. The resident reported not receiving any air, and a CNA removed the portable oxygen tank without placing the resident on an oxygen concentrator. The LPN was aware of the situation but did not immediately address it due to being busy with medication pass. The resident's medical record indicated a diagnosis of hypoxemia and other conditions requiring continuous oxygen at 3 LPM, but the care plan lacked documentation for oxygen use. Resident 8 was observed lying in bed with a nebulizer mask removed and placed on the bed. The LPN did not clean the medication chamber after the treatment and failed to assess the resident before or after the nebulizer treatment. The resident confirmed that nurses sometimes did not assess her lungs before or after treatments. The medical record for Resident 8 included diagnoses such as chronic obstructive pulmonary disease and pulmonary hypertension, with physician orders for regular nebulizer treatments and oxygen at 5 LPM. The care plan indicated the resident received continual oxygen and nebulizer treatments as ordered. The facility's policies for oxygen concentrators and nebulizer treatments were not followed. The oxygen concentrator policy required verification of the physician's order and adjustment of the flow meter to the prescribed setting. The nebulizer policy required the nurse to stay with the resident during the entire medication administration and to clean and dry the nebulizer equipment properly. These procedures were not adhered to, leading to deficiencies in the respiratory care provided to the residents.
Failure to Provide Necessary Mental Health Services
Penalty
Summary
The facility failed to provide necessary mental health services to Resident 48, who exhibited significant behavioral health issues. On 5/09/24, during an observation and interview, Resident 48 was found to be very confused, crying, and expressing a desire to leave the facility. The staff indicated that the resident was an elopement risk and had been trying to leave the facility. The resident's medical record, reviewed on 5/14/24, included diagnoses of severe dementia with behavioral disturbances, depression, and a psychotic disorder with delusions. Despite these diagnoses, the resident's care plan and physician orders did not adequately address her behavioral health needs, and there was a lack of documentation regarding consultation with the family about psychiatric services. The Social Services Director acknowledged the need for psychiatric services but noted that the family was reluctant to allow these services, and there was no documentation of discussions with the family about this issue. The facility's policy on behavioral health, provided by the Director of Nursing, indicated that residents should be assessed for behavioral health needs and referred to behavioral health providers when necessary. However, the facility did not follow this policy for Resident 48, as evidenced by the lack of timely psychiatric consultation and inadequate documentation of family discussions. The resident's medical record showed several entries of behaviors including agitation and exit-seeking, yet the quarterly Minimum Data Set (MDS) assessment did not reflect any behavioral symptoms during the look-back period. This discrepancy further highlights the facility's failure to provide appropriate mental health services to Resident 48, leading to the deficiency noted in the report.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in an observed error rate of 6.45%. One incident involved an LPN administering Creon to a resident with chronic pancreatitis by touching the capsule with an ungloved finger, which is against the facility's medication administration policy. The Director of Nursing confirmed that medications should not be administered if touched by bare hands, and the facility's policy documents corroborated this procedure requirement. Another incident involved an LPN administering 3 units of insulin lispro to a resident with type 2 diabetes and hyperosmolarity. The insulin was administered at 11:10 a.m., but the resident did not receive their lunch meal until 11:52 a.m., which is beyond the 15-minute window recommended by the manufacturer's guidelines for fast-acting insulin. The Director of Nursing confirmed that residents receiving fast-acting insulin should get their meal within 15 minutes of administration. These actions led to a medication error rate exceeding the acceptable threshold.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Williamsport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Covington, The | 11.6 mi | ★★★★★ | 27 | 2 |
| Hawthorne Inn Of Danville | 18.8 mi | ★★★★★ | 2 | 0 |
| La Bella Of Danville | 18.9 mi | ★★★★★ | 16 | 3 |
| Accolade Healthcare Danville | 21.3 mi | ★★★★★ | 7 | 0 |
| University Place Health Center And Assisted Living | 21.7 mi | ★★★★★ | 5 | 0 |
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