Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Abbeyville Skilled Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Emergency Hospital Transfers: The facility did not notify the State LTC Ombudsman of emergency hospital transfers for multiple residents. Records showed residents were sent out for issues such as abnormal vitals, respiratory distress, falls, hypotension/syncope, dyspnea, hypoxia, sepsis, UTI, pain, and abdominal symptoms, and several were later readmitted or died at the hospital. Interviews with the NHA confirmed that required Ombudsman notification was not sent for some of the transfers.
A resident with vascular dementia did not have a baseline care plan meeting to address immediate needs within 48 hours of admission. Social services documented one attempt to schedule the meeting when the resident was sleeping, and the resident’s representative later confirmed that no care plan meeting had occurred since admission. The NHA confirmed no further contact was made to schedule the meeting.
A resident was not included in the comprehensive care plan process. The resident stated they had not been invited to a care plan conference, and the record showed a quarterly MDS was completed but no evidence of a care plan meeting or invitation was found. The NHA confirmed there was no evidence the meeting was held or that the resident was invited.
Failure to Follow Physician Orders for Weights and Midodrine Administration: The facility failed to follow physician orders for two residents. One resident with HF, hypomagnesemia, severe protein-calorie malnutrition, and adult failure to thrive did not receive ordered weekly Wednesday weights consistently. Another resident with orthostatic hypotension and CAD received Midodrine 2.5 mg TID PRN for SBP <=100 even when SBP readings were above 100 mmHg. The NHA confirmed both order-following failures.
Missing Monthly Medication Regimen Reviews: The facility failed to ensure a licensed pharmacist completed and documented monthly MMRs for two residents. For one resident, several pharmacist recommendations referenced in the chart were not available, and for another resident, records showed MRRs only for a few months with no evidence of additional monthly reviews. The NHA confirmed the missing documentation.
The facility failed to notify the physician of significant weight gains for two residents, as required by their policy and physician orders. One resident had a 3.5-pound weight gain in one day, and another had a 20-pound gain over two days, but neither physician was notified. These oversights were confirmed by interviews with the Nursing Home Administrator and the Director of Nursing.
A resident with intact cognition reported being hit by a staff member, but the facility failed to investigate the incident. The resident later did not recall the event, and the Director of Nursing confirmed no investigation was conducted, violating state codes on abuse reporting and management responsibilities.
The facility failed to complete the required PASRR for two residents, which is necessary for identifying mental illness or intellectual disabilities and ensuring appropriate placement and services. A resident was readmitted without a completed PASRR, and the NHA confirmed this oversight, violating regulations on clinical records and social services.
A facility failed to implement a baseline care plan for a resident with a Foley catheter upon admission. The resident was admitted with the catheter, but the care plan lacked any documentation addressing its management. This was confirmed by the Nursing Home Administrator during an interview.
The facility failed to notify the State Long-Term Care Ombudsman of emergency hospital transfers for four residents, including those with pneumonia, critical potassium levels, shortness of breath, and acute kidney injury. This deficiency was confirmed through record reviews and staff interviews, with the Nursing Home Administrator acknowledging the oversight.
A facility failed to provide timely interventions and wound monitoring for a resident at risk for pressure ulcers. Despite being identified as at risk, the care plan was delayed, and interventions were not promptly implemented. The resident developed a stage two pressure ulcer, and follow-up skin checks were not conducted as required. The DON confirmed that scheduled wound rounds were not completed, contributing to the deficiency.
The facility failed to implement effective infection control measures, with staff observed not adhering to PPE guidelines, such as wearing N95 respirators, while interacting with COVID-19 positive residents. Additionally, the facility did not conduct contact tracing after a staff member tested positive, contributing to an outbreak on the Arcadia Unit.
A resident with Parkinson's did not receive their prescribed Rytary medication nine times due to pending pharmacy delivery, despite the medication being delivered. The physician was not notified of the missed doses, and the DON could not explain the failure.
A resident admitted for short-term rehabilitation after surgery did not have a baseline care plan established for their surgical wound. This oversight was confirmed by both a licensed employee and the Interim DON, indicating a lapse in the facility's admission procedures.
A resident admitted for short-term rehabilitation after surgery did not receive a shower from admission until mid-August. Interviews with staff, including an LPN and the Interim DON, confirmed the lack of bathing services, despite no clinical reason to withhold them. This issue was cited under nursing services regulations, with previous citations noted.
A resident admitted for short-term rehabilitation after surgery had a surgical wound on the mid-back that was not assessed for signs of infection. Despite physician orders for daily wound care, the treatment was missed on two occasions, and no assessments were documented from admission until the infection was identified. The resident reported increased pain, and a nurse practitioner confirmed an infection, leading to a new treatment plan.
A resident, admitted for post-abdominal surgery therapy and requiring substantial assistance, reported feeling unsafe due to rough handling by a male nurse. Despite the resident's daughter reporting the incident to the charge nurse, the facility failed to conduct a timely investigation as required by their abuse prohibition policy. The Nursing Home Administrator was not informed of the complaint until days later, and no documented evidence of an investigation was provided.
The facility failed to ensure a safe and sanitary environment, as mouse droppings were found in a resident's room and remained unaddressed for hours. Additionally, broken tiles and a hole in a bathroom wall were not reported to maintenance. These issues were confirmed through staff interviews, indicating lapses in communication and environmental management.
A resident with a surgical wound and wound VAC experienced a lapse in care due to the facility's failure to maintain the wound VAC as ordered. The wound VAC was non-functional for nearly a week due to a depletion of canisters, despite the facility's awareness and attempts to obtain the necessary supplies.
The facility failed to have an effective pest control system on the dementia unit. An employee and a resident reported frequent sightings of mice. Mouse droppings were observed on a nightstand, and the pest control logs showed the last visit was on an unspecified date. The Nursing Home Administrator confirmed awareness of the issue.
Failure to Notify Ombudsman of Emergency Hospital Transfers
Penalty
Summary
The facility failed to notify the office of the state long term care ombudsman of emergency hospital transfers for 10 of 31 residents reviewed. The deficiency involved Residents 1, 10, 14, 20, 46, 84, 91, 126, 134, and 165, whose records showed transfers to the hospital or emergency department for conditions including abnormal vital signs, respiratory distress, an unwitnessed fall, hypotension and syncope, dyspnea, hypoxia, emphysematous cystitis, sepsis, constipation with urinary tract infection, pain, a fall with femur fracture, and intractable vomiting with abdominal pain. Resident 1 was transferred to the hospital for abnormal vitals and later readmitted, but the record did not show that the State Ombudsman was notified. Resident 10 had multiple hospital transfers for respiratory distress, an unwitnessed fall with hypotension and syncope, and dyspnea, with no evidence of Ombudsman notification. Resident 14 was transferred for worsening discoloration of the toes, and Resident 20 was transferred after a fall resulting in a right femur fracture; both were readmitted and their records did not show notification to the State Ombudsman. Additional records showed Resident 46 was sent to the emergency department and admitted for hypoxia, Resident 84 was transferred to the local hospital with emphysematous cystitis, Resident 91 was transferred for sepsis, Resident 126 had several hospital transfers including for constipation, UTI, pain, and a resident-requested transfer later resulting in a pulmonary embolism, Resident 134 was transferred after a fall, and Resident 165 was transferred for evaluation after intractable vomiting and abdominal pain and died at the hospital. Interviews with the Nursing Home Administrator confirmed that notification to the Office of the State Long Term Care Ombudsman was not sent for several of these transfers as required.
Failure to Hold Baseline Care Plan Meeting
Penalty
Summary
The facility failed to conduct a baseline care plan meeting to create a plan for meeting the resident’s most immediate needs within 48 hours of admission for one resident with vascular dementia. The resident was admitted to the facility on [DATE], and a social services progress note dated March 11, 2026, documented that an attempt had been made to schedule a meeting with the resident, but the resident was sleeping. The resident’s representative stated on March 30, 2026, that neither the resident nor the representative had had a care plan meeting to establish a baseline care plan since admission. The Nursing Home Administrator confirmed on April 3, 2026, that no further contact had been made with the resident or the representative to schedule the baseline care plan meeting.
Resident Not Included in Care Plan Conference
Penalty
Summary
The facility failed to ensure that Resident 3 or the resident's representative was included in the resident's comprehensive care plan. Resident 3 stated during interview on March 30, 2026, that the resident had not been invited to a care plan conference. Review of the clinical record showed that a quarterly MDS was completed on February 17, 2026, but there was no evidence that a care plan meeting was held or that the resident was invited to the meeting. The Nursing Home Administrator confirmed on April 2, 2025, that there was no evidence of a care plan meeting or an invitation to the resident.
Failure to Follow Physician Orders for Weights and Midodrine Administration
Penalty
Summary
The facility failed to follow physician orders for two residents. One resident had diagnoses including heart failure, hypomagnesemia, severe protein-calorie malnutrition, and adult failure to thrive, and had a physician order for weekly weights every Wednesday starting February 25, 2026. The clinical record showed that weights were not obtained on February 25, March 11, March 18, and March 25, 2026, and the record did not show evidence that the ordered weekly Wednesday weights were consistently completed. The Nursing Home Administrator confirmed that the physician orders for weekly Wednesday weights were not being followed. A second resident had diagnoses including orthostatic hypotension and coronary artery disease and had a March physician order for Midodrine 2.5 mg by mouth three times daily, to be given only if systolic blood pressure was 100 mmHg or less. The MAR showed Midodrine was administered on multiple occasions when the resident’s systolic blood pressure was above 100 mmHg, including readings such as 109/62, 114/67, 128/64, 110/47, 108/53, 101/54, 124/63, 109/69, 114/64, 110/50, 107/54, 132/55, 103/67, 110/60, 127/80, 119/81, and 103/53. The Nursing Home Administrator confirmed that the medication was not administered according to the physician’s orders.
Missing Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly Medication Regimen Reviews (MMR) as required for two residents reviewed. The facility’s policy stated that the MMR includes review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities, and that the pharmacist collaborates with the interdisciplinary team, including the resident and/or representative. For Resident 6, the clinical chart showed pharmacist recommendations documented in the progress notes tab under Medication Regimen Review on multiple dates between March 2025 and December 2025, but the facility was unable to provide the pharmacist’s recommendations for several of those reviews, including June 2025, July 2025, September 2025, October 2025, November 2025, and December 2025. The Nursing Home Administrator confirmed that those recommendations were not available. For Resident 12, facility documentation showed MRRs for January 2026, February 2026, and March 2026, but no evidence of completed MMRs for any additional months was found, and the NHA confirmed that the MRRs were not available.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician of significant weight gains for two residents, as required by their own policy and physician orders. Resident 76 had a physician order to be weighed daily, with instructions to notify the physician if there was a weight gain of 1 pound in one day or 3 pounds in one week. On January 22, 2025, Resident 76 experienced a 3.5-pound weight gain in one day, but there was no evidence in the clinical record that the physician was notified of this change. This was confirmed by an interview with the Nursing Home Administrator. Similarly, Resident 147 had an order for weights to be obtained on Monday, Wednesday, and Friday for monitoring purposes. On November 20, 2024, Resident 147 showed a 20-pound weight gain over two days, yet the clinical record lacked documentation of physician notification. This oversight was confirmed by an interview with the Director of Nursing. These failures to notify the physician of significant weight changes are in violation of the facility's policy and procedure titled Weights and Heights, revised in 2023.
Failure to Investigate Suspected Abuse Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an incident involving suspected abuse of a resident. According to the facility's Abuse Prohibition policy, employees are mandated reporters and must immediately report any reasonable suspicion of a crime against a patient. On October 6, 2024, a resident with intact cognition reported being hit multiple times by a staff member during the evening shift. However, the nursing documentation noted that the resident made false accusations and was unable to confirm the incident when questioned. The resident was educated on not making false accusations, but there was no care plan addressing false accusations, nor was there any other documentation of such behavior in the resident's clinical record. The facility's Director of Nursing confirmed that no investigation was conducted regarding the incident. An interview with the resident in February 2025 revealed that the resident did not remember the incident. The facility's failure to investigate the report of suspected abuse is a violation of the responsibility of the licensee and management as per the relevant state codes. The lack of an investigation into the resident's allegations represents a deficiency in the facility's handling of suspected abuse cases.
Failure to Complete PASRR for Two Residents
Penalty
Summary
The deficiency involves the failure to complete the Preadmission Screening and Resident Review (PASRR) for two residents, Resident 60 and Resident 92, as required by the Omnibus Budget Reconciliation Act (OBRA) of 1987. The PASRR is essential for identifying individuals with mental illness or intellectual disabilities, ensuring appropriate placement, and providing necessary services. Resident 60 was readmitted to the facility in August 2025, but a review of their clinical record did not produce a completed PASRR. The Nursing Home Administrator confirmed via email that the PASRR was not completed for Resident 60. This oversight is a violation of the regulations outlined in 28 Pa Code 211.5(f) regarding clinical records and 28 Pa Code 211.16(a) concerning social services.
Failure to Implement Baseline Care Plan for Foley Catheter
Penalty
Summary
The facility failed to ensure a baseline care plan was in place for a resident with a Foley catheter upon admission. The clinical record review revealed that the resident was admitted to the facility with a Foley catheter on January 14, 2025. However, the care plan for the resident did not include any evidence of a care plan addressing the management of the Foley catheter. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 6, 2025, who acknowledged the absence of a baseline care plan for the resident's Foley catheter.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the Office of the State Long-Term Care Ombudsman regarding emergency hospital transfers for four out of five residents reviewed. Specifically, Residents 12, 29, 78, and 130 were transferred to hospitals for various medical emergencies, including pneumonia, critical potassium levels, shortness of breath, and acute kidney injury. Despite these transfers, the facility did not notify the Ombudsman as required. The deficiency was confirmed through clinical record reviews and staff interviews, revealing that the facility had not notified the Ombudsman of any hospital transfers since September 2024. This oversight was acknowledged by the Nursing Home Administrator during an interview conducted via email. The report also notes that this issue had been previously cited on multiple occasions throughout 2024, indicating a recurring problem with compliance in this area.
Failure to Provide Timely Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide timely interventions for a resident at risk for developing a pressure ulcer and did not conduct timely wound monitoring. The facility's policy on Skin Integrity and Wound Management requires that the plan of care reflect assessment findings and that staff continually observe and monitor patients for changes, implementing revisions as needed. However, for a resident newly admitted with acute respiratory failure, a tracheostomy, and mouth cancer, the facility did not develop a care plan addressing the risk for skin breakdown until three days after the resident was assessed to be at risk for developing a pressure ulcer. The resident's admission assessment noted redness on the sacrum, and the Braden Scale indicated the resident was at risk for pressure ulcers. Despite the resident being identified as at risk, the care plan was delayed, and interventions such as pressure redistribution surfaces and wound treatment were not implemented promptly. Additionally, the facility failed to conduct a follow-up skin check after the resident developed a stage two pressure ulcer on the sacrum. An interview with the Director of Nursing revealed that wound rounds were scheduled but not conducted as planned, and the care plan with interventions was not developed until after the pressure ulcer was identified. This lack of timely intervention and follow-up contributed to the deficiency.
Inadequate Infection Control Measures Observed
Penalty
Summary
The facility failed to implement effective infection prevention and control measures as observed on two of four units, as well as in the reception and Rehab department. The Pennsylvania Department of Health's guidelines recommend the use of NIOSH-approved N95 respirators, gowns, gloves, and eye protection for healthcare personnel entering rooms of patients with suspected or confirmed COVID-19. However, multiple staff members were observed not adhering to these guidelines, with some wearing surgical masks improperly or not at all while interacting with residents, including those on contact and droplet precautions. The facility's policy requires special contact and droplet precautions for residents suspected or confirmed to have COVID-19, including wearing an N95 respirator and keeping the patient's room door closed. Despite this, staff members were observed not following these precautions. For instance, a licensed nurse was seen providing aerosol treatment to a COVID-19 positive resident while only wearing a surgical mask, contrary to the required PPE. Additionally, there was a failure to conduct contact tracing after a staff member tested positive for COVID-19, which could have helped identify potential exposures among staff and residents. The report also highlights an incident where two residents from the Arcadia Unit were hospitalized and tested positive for COVID-19, leading to an outbreak on the unit. Despite the outbreak, the facility did not conduct contact tracing to determine possible contacts of the staff who tested positive, some of whom worked across multiple units. This lack of contact tracing and adherence to PPE guidelines contributed to the facility's failure to manage infection control effectively.
Failure to Administer Prescribed Medication for Parkinson's
Penalty
Summary
The facility failed to administer the prescribed medication Rytary to Resident CL1, who has Parkinson's disease, as per the physician's order. The order, dated November 23, 2024, required the administration of three capsules of Rytary three times a day. However, from November 24 to November 30, 2024, the medication was not administered nine times due to pending delivery from the pharmacy. Despite the pharmacy delivering 27 capsules, the medication was not given, and there was no documentation of the physician being notified about the missed doses. An interview with the Director of Nursing confirmed the lack of notification to the physician and provided no explanation for the failure to administer the medication.
Failure to Establish Baseline Care Plan for Surgical Wound
Penalty
Summary
The facility failed to establish a baseline care plan for a resident who was admitted for short-term rehabilitation following surgery. Upon review of the clinical records, it was found that there was no evidence of a baseline care plan addressing the presence and care of the resident's surgical wound. This deficiency was confirmed through interviews with a licensed employee and the Interim Director of Nursing, both of whom acknowledged that the baseline care plan was not established upon the resident's admission.
Failure to Provide Bathing Services
Penalty
Summary
The facility failed to provide bathing or showering services to a resident who was admitted for short-term rehabilitation following surgery. The clinical record review for this resident showed no evidence of a shower being provided from the time of admission until August 13, 2024. Interviews with a licensed employee and the Interim Director of Nursing confirmed that the resident had not received a shower since admission, despite there being no clinical reason to withhold such care. This deficiency was noted under the 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services, which had been previously cited on multiple occasions.
Failure to Assess Surgical Wound Leads to Infection
Penalty
Summary
The facility failed to assess a surgical wound for signs and symptoms of infection for a resident who was admitted for short-term rehabilitation following surgery. The resident had a surgical wound located on the mid-back, and physician orders upon admission specified that the incision should be cleansed with normal saline, dried well, and left open to air every day shift. However, the treatment was not administered on two specific days, and there was no documented evidence of any wound assessment from the time of admission until the infection was identified. The resident reported increased pain and was seen for complaints of infection to the surgical incision. A nurse practitioner later confirmed an incisional infection and prescribed antibiotics and a new wound care regimen. An interview with the Interim Director of Nursing confirmed that no skin or surgical wound assessments were conducted from the time of admission until the infection was identified, indicating a lapse in the facility's nursing services.
Failure to Investigate Allegation of Rough Handling
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of rough handling by a resident who expressed feeling unsafe. The facility's policy on abuse prohibition requires an investigation to be initiated within 24 hours of receiving a report of suspected or alleged abuse. However, in this case, the investigation was not conducted in a timely manner. Resident CL1, who was cognitively intact and required substantial assistance with toileting, was admitted to the facility for therapy post-abdominal surgery. On the day of the incident, the resident was visibly upset and expressed a desire to leave the facility, citing feelings of unsafety. The resident's daughter reported care concerns involving a male nurse, including inappropriate assistance with toileting and rough handling, to the charge nurse, who assured her that the issue would be reported to a supervisor. Despite these reports, the facility did not provide documented evidence of an investigation into the allegations. The Nursing Home Administrator (NHA) was not informed of the email sent to the compliance department until several days later, and the alleged perpetrator, an agency staff member, was no longer allowed in the facility. The lack of a documented investigation into the resident's allegations of rough handling constitutes a failure to adhere to the facility's policy and regulatory requirements, as outlined in the relevant Pennsylvania Code sections.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in one of its units, as evidenced by multiple observations and staff interviews. During an observation in a resident's room, numerous black pellet-like objects, identified as mouse droppings, were found on the bottom wall vent and the floor beneath the television. Despite the presence of these droppings, they remained in the room hours later, indicating a lack of timely cleaning or pest control measures. Additionally, a separate observation in a bathroom revealed broken tiles and a hole in the bottom wall, which had not been reported to the maintenance director. These deficiencies were confirmed through interviews with a licensed nurse and the maintenance director, highlighting a failure in communication and environmental management within the facility.
Failure to Maintain Wound VAC Due to Supply Depletion
Penalty
Summary
The facility failed to ensure that Resident R1 received treatment and care in accordance with professional standards of practice. Resident R1 was admitted with a surgical wound to the right lower leg and had a wound VAC in place. The physician's order specified that the wound VAC dressing should not be changed by the facility staff and that the resident should be monitored and seen by trauma and acute care for wound VAC changes. However, due to a positive flu test, Resident R1's follow-up appointment was rescheduled, and the wound VAC was not operational for several days due to a depletion of canisters. Despite the facility's awareness of the need for canisters and attempts to obtain them, the wound VAC remained non-functional for nearly a week, as confirmed by staff and the Director of Nursing (DON). The resident confirmed that the wound VAC had not been operational for close to a week, and the facility was unable to maintain the wound VAC as required by the physician's order due to supply issues and vendor changes. The deficiency was further highlighted by multiple progress notes and eMAR entries indicating the wound VAC was off due to the lack of canisters. Staff interviews corroborated the issue, revealing that the central supply was aware of the need for canisters, but the facility was in the process of switching vendors and could not obtain the necessary supplies. The DON confirmed that despite efforts to call other facilities and locate canisters, the wound VAC was not consistently operational since the initial depletion of supplies. This failure to maintain the wound VAC as ordered resulted in a lapse in the resident's prescribed wound care treatment.
Ineffective Pest Control on Dementia Unit
Penalty
Summary
The facility failed to have an effective pest control system on the dementia unit (Arcadia). Employee E4 revealed that mice were a significant issue on the unit, with sightings being a common occurrence both day and night. During a tour of the Arcadia unit, mouse droppings were observed on the nightstand next to a resident's bed. Another resident confirmed frequent sightings of mice in the unit and their room, with the most recent sighting occurring the previous night. The review of pest control logs indicated that the pest control company last visited the facility on an unspecified date. The Nursing Home Administrator confirmed awareness of the ongoing mice problem.
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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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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hamilton Arms Center | 0.6 mi | ★★★★★ | 7 | 0 |
| Homestead Village, Inc | 1.1 mi | ★★★★★ | 2 | 0 |
| Rose City Nursing And Rehab At Lancaster | 1.7 mi | ★★★★★ | 16 | 1 |
| Trillium Place | 2 mi | ★★★★★ | 1 | 0 |
| Calvary Fellowship Homes Inc | 2.6 mi | — | 0 | 0 |
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