Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Athens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food storage and sanitation deficiencies were observed in the main kitchen and on Sage unit. The cook’s fridge contained dated food items, bread and buns lacked date labels, and the dishwasher unit had peeling thermal tape. On Sage, the pantry sink area had dried spills and water damage, the condiment tray contained open and contaminated items, the refrigerator held spoiled-looking grapes and dust, and the ice machine area showed a blackened drainage tube, a possible leak, and debris under the machine.
A facility failed to adequately monitor psychotropic medication regimens for two residents. One resident with depression and anxiety had multiple Fluoxetine dose changes and reported tremors that limited shaving and holding a cup, while psych notes also documented severe depression and suicidal statements; however, the MAR/TAR did not show ongoing monitoring of behavioral symptoms or adverse effects. Another resident was receiving Sertraline, Trazodone, and Risperdal, but the MAR/TAR did not show ongoing monitoring of negative behaviors related to depression. The DON confirmed the findings.
A facility failed to follow physician-ordered interventions for three residents. One resident with CHF and CKD was on a 1500 mL fluid restriction, but staff documented intakes above the limit and did not address his noncompliance; another resident had ordered tubigrips for bilateral LE swelling but was observed without them despite MAR/TAR initials; and a third resident had ace wraps on both legs without a physician order, with the wrap on one leg unwinding and rolled. Podiatry notes for the resident with ace wraps documented absent pulses, nail thickening, callus, dry skin, and edema.
The facility failed to develop and implement individualized person-centered care plans for two residents with dementia and cognitive loss. Both residents were assessed as having dementia on MDS review, and care plans were expected to address their cognitive needs, but chart review showed no documentation that person-centered dementia care plans had been developed or implemented. A social worker confirmed the findings, and the DON could not provide additional documentation.
The facility failed to follow TBP and EBP for multiple residents, including an LPN providing wound care to a resident with a surgical incision without a gown and staff entering rooms of residents on contact precautions without proper PPE or hand hygiene. An LPN also failed to perform hand hygiene between glove changes and after glove removal during med pass for a resident. In the laundry area, soiled laundry handling and handwashing practices were inconsistent, and the facility did not have an individualized Legionella water management program.
Failure to Offer Pneumococcal Immunizations: The facility did not ensure pneumococcal vaccines were offered in accordance with CDC guidance for three residents reviewed. One resident had prior Prevnar13 with no evidence of any additional pneumococcal vaccine despite consent, another resident with no prior pneumococcal history received PPSV23 instead of the indicated PCV option, and a third resident became eligible for a pneumococcal revaccination but there was no evidence it was offered. The DON confirmed the findings.
Failure to Document and Offer COVID-19 Immunizations: The facility did not ensure that several residents were offered or documented as receiving the COVID-19 vaccine despite consent forms showing verbal permission or consent from family members or the resident. In addition, the DON stated the facility had no evidence of staff COVID-19 immunization documentation, and while staff were asked for vaccine proof at hire, the facility did not offer or document staff COVID-19 immunizations afterward.
Failure to Protect Resident Dignity: Staff entered a resident’s room without knocking despite the resident’s preference for privacy, and another resident with nephrostomy tube care was observed with urinary catheter bags left uncovered and visible while sitting, eating, and ambulating. The DON and NHA were informed of the concerns after the observations.
A resident was given ordered Voltaren gel in a souffle cup by an LPN and carried it to his room, where he stated he would apply it later. The record contained no evidence that the IDT assessed whether he could safely self-administer the medication, and the NHA and DON confirmed the assessment had not been done before surveyor questioning.
The facility failed to ensure quarterly personal fund statements were provided to the resident or responsible party for two residents whose money was held by the business office. One resident had severe cognitive impairment and a POA daughter who said she did not receive the statement, while the other resident had no cognitive impairment but stated she did not know who received the statement. Staff reported that statements were printed and placed in an activities box for delivery, but the activities director could not recall which residents received them.
Housekeeping and maintenance failed to keep the Ivy unit clean, safe, and orderly. One resident’s room had a strong urine-like odor, sticky flooring, and soiled linens left in a bag with some linens on top, while the resident said she is incontinent, urinates on the floor, and cleans it herself. Another resident’s bathroom had a sticky floor and a stained counter, and the resident said housekeeping cleans bathrooms about once a week. The wall near the NS also had handrail paint scraped off, exposing bare metal.
A resident was transferred to the ER by 911 for back pain, and nursing documentation noted the sister was informed of the transfer. Although the resident’s profile listed the sister as his representative, the eINTERACT transfer form sent to the hospital identified the resident as his own representative and did not include the sister’s contact information, as confirmed by the DON.
A resident’s MDS failed to accurately code a fall-related injury as major after the resident was found on the floor with back pain, sent to the ER, and later hospitalized for a T7-T8 unstable fracture requiring surgery. The assessment instead coded the fall as an injury that was not a major injury, despite hospital documentation confirming vertebral fractures.
A resident’s care plan was not revised to include an active order for daily tubigrips to both lower extremities. Record review showed the order was in place, observation found the resident’s lower legs and ankles swollen and the tubigrips not on, and the care plan contained no intervention for daily tubigrip use even though the MAR/TAR showed staff initials documenting application.
Failure to provide required bathing assistance: A resident assessed as dependent for bathing was observed with greasy hair and could not recall when she last received a shower. Her care plan required weekly bathing, but ADL documentation showed only four showers/baths over several months, with no documentation that staff offered or that she refused bathing during the cited period. The DON was unable to provide additional documentation that bathing assistance had been provided.
Failure to implement fall-prevention interventions for two residents. One resident had a prior shower fall and the IDT identified non-slip strips for the shower, but none were present when observed. Another resident’s care plan included a “Call don’t Fall” sign for fall risk, but no sign was hanging in the room, and an LPN confirmed it was not present.
The facility failed to provide competency documentation for two RNs related to medication administration, lifts, wound vac care, catheter care, dressing changes, IV therapy, and PICC line care. The record showed residents in the facility required these services, but the DON confirmed there was no documentation that the two RNs had the specific competencies and skill sets needed for the residents' care needs.
Failure to Address Pharmacy Recommendations and Monthly Drug Review: The facility did not ensure that physician responses to consultant pharmacist recommendations were timely or documented for two residents. One resident's PEG order change was not addressed for over two months, while another resident had unresolved pharmacy requests for a diagnosis for Klonopin and lab monitoring for atorvastatin, magnesium, and Depakote, and the facility could not provide documentation of a monthly pharmacy review for one month.
Failure to provide routine dental services for two residents was identified. One resident had broken or likely cavity-affected natural teeth, a dental care plan, and limited dental documentation, but no evidence of twice-yearly professional dental services under the State plan. Another resident was edentulous, reported not being offered a dentist since admission, had ill-fitting dentures at home, and the facility could not produce documentation that dental services were offered despite a care plan noting dental consultation as needed.
A facility failed to maintain an accurately documented clinical record for one resident. Nursing notes documented the resident as deceased with no respirations or heart sounds and recorded a time of death, while a later physician discharge note still included care plan comments about diet and fluid status. The discrepancy was reviewed with the NHA and DON.
QAPI committee attendance records showed the facility did not hold a meeting during the first quarter and that the Infection Preventionist did not attend the documented meeting. The NHA confirmed the findings during interview.
Failure to post daily nurse staffing information was identified at two nursing stations, Ivy and Sage. Surveyors observed no evidence that staffing hours were posted, and review of the facility’s staffing postings showed numerous missing first, second, and third shift entries across multiple days. The DON confirmed the findings.
The facility did not employ a full-time qualified dietitian and also lacked a qualified director of food and nutrition services, as the current dietary manager did not meet certification or educational requirements. This was confirmed through staff interviews and by the Nursing Home Administrator.
Surveyors observed unsanitary conditions in the main kitchen and two nursing units, including food debris and buildup in steam table wells, uncovered and undated milk cups in a cooler, dirty ceilings and light covers, porous wood shelving with stains, and soiled floors and equipment in pantries and refrigerators. These issues were identified during inspection and reviewed with the NHA and DON.
Staff used personal electronic devices to access and document resident medical records because there were not enough facility-supplied laptops and iPads available. This practice occurred during medication administration and routine care, despite staff having received training on HIPAA and confidentiality. The facility was unable to ensure the security and privacy of resident information as a result.
A resident with an Aspira catheter did not receive care as ordered by the physician, as only RN staff were authorized to perform drainage, dressing changes, and valve changes, but LPN staff completed these tasks on several occasions. Documentation was missing for required RN interventions, and only RNs received education on Aspira catheter care.
A resident's clinical record contained conflicting documentation regarding advance directives, with a physician's order for DNR status and a signed POLST indicating full code status. There was no evidence of updated documentation or discussions clarifying the resident's wishes for life-sustaining treatment.
Surveyors found that two residents' rooms had exposed drywall paper near the bathroom doors, partially covered by hand sanitizer dispensers. The hallway had a handrail with worn-off paint exposing metal, dried brown liquid splatter behind medication carts, and a vent above the nursing station with visible dust extending to ceiling tiles.
Two residents with orders for chair alarms to prevent falls were repeatedly observed in wheelchairs without the required alarms in place. Staff confirmed the absence of these alarms, despite care plans and physician orders specifying their use and regular checks.
A registered nurse did not follow Enhanced Barrier Precautions by failing to wear a gown during a chest tube dressing change for a resident with indwelling medical devices, despite an active order and posted signage requiring EBP. This action did not comply with CMS requirements for gown and glove use during high-contact care activities.
The facility did not notify the State Long-Term Care Ombudsman when several residents were transferred to the hospital following changes in their conditions. Clinical records showed that, despite hospital admissions, there was no documentation of the required notifications, and the administrator confirmed that such notifications were not being sent.
The facility did not include pharmacy or laboratory personnel in its infection control committee meetings, as required by the Act 52 Infection Control Plan. Attendance records for QAPI meetings showed no evidence of participation from these disciplines, despite regulatory requirements for a multidisciplinary committee.
Nurse aides were not properly evaluated for competency in essential care skills, including safe transfer techniques, as the facility relied solely on staff acknowledgment of training materials without requiring return demonstrations or direct observation. An LPN confirmed that this was the standard procedure for all nurse aides, and documentation for several aides lacked evidence of skill verification.
Two residents were involved in incidents where hazardous and illegal smoking materials, including marijuana, cigarettes, and a vape device, were present and used in their rooms. Despite LPNs and social services staff documenting these events and notifying supervisory staff, there was no evidence of investigation or remedial action by facility administration to address or remove the hazards.
The facility did not follow its own policies or CDC guidance for COVID-19 infection control, allowing two LPNs to return to work before meeting return-to-work criteria and failing to conduct contact tracing or testing for residents exposed to COVID-19. Several residents who were diagnosed with COVID-19 did not have appropriate transmission-based precautions initiated, and universal source control measures were not in place during the outbreak.
The facility failed to provide complete discharge summaries for two residents, lacking evidence of medication reconciliation and receipt by the residents or their responsible parties. Discharge documentation for one resident did not include medication reconciliation, while the other resident's summary lacked documentation of medication disposition.
The facility failed to ensure proper infection control for two residents with COVID-19, as signage for droplet precautions was inadequate and PPE usage was unclear. Observations showed that signs did not include necessary eye protection instructions, and staff used incorrect masks due to unclear guidance. Interviews confirmed these deficiencies, highlighting a failure to adhere to CDC guidelines.
The facility's main kitchen had multiple sanitation and food storage deficiencies, including dead insects in light covers, unlabeled and undated food items, and debris build-up on surfaces. The refrigerator and freezer had temperature issues and ice build-up, with no corrective actions documented. These findings were reviewed with the Dietary Manager, Nursing Home Administrator, and DON.
The facility failed to provide written notification of the state bed-hold policy to residents or their representatives during hospital transfers or therapeutic leave. This deficiency affected six residents, with no evidence of notification provided during multiple hospitalizations. The issue was confirmed during staff interviews and represents a recurring compliance problem with resident rights regulations.
The facility failed to ensure that pharmacy recommendations were addressed for four residents. For one resident, recommendations made by the pharmacist were not documented or acted upon, as confirmed by the DON. Another resident's record lacked documentation of multiple pharmacy recommendations, and the Administrator confirmed these findings. Additionally, a resident's record indicated recommendations were made, but there was no Clinical Pharmacy Report or documentation of actions taken by a physician.
The facility failed to maintain accurate clinical documentation for two residents. One resident's records incorrectly indicated ongoing hospice care despite discharge, while another resident's records erroneously included a discontinued medication. These errors were confirmed by facility staff.
The facility's arbitration agreements for several residents failed to ensure a neutral arbitration process, allowing the facility to select the arbitrator if parties could not agree within 30 days. This was confirmed by staff interviews and discussions with the administration.
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents with indwelling devices or wounds, as required by CMS guidelines. Observations showed a lack of PPE and signage in residents' rooms, and improper storage of a urinary collection bag. Staff interviews confirmed inadequate communication and implementation of EBP.
The facility failed to have a qualified Infection Preventionist after the previous Director of Nursing left. A licensed practical nurse took over the role without specialized training. The facility lacked evidence of infection control meetings and proper monitoring of infections and antibiotic use. The Director of Nursing was unaware of who managed the Pennsylvania Patient Safety Reporting System.
The facility did not offer updated COVID-19 vaccines to four residents, as required by CDC guidelines. The facility's policy lacked provisions for educating residents about the vaccine, and there was no documentation of vaccine administration. Interviews confirmed no evidence of education or vaccine offers to these residents.
Two residents in the facility did not receive proper pressure ulcer care as per physician's orders, with missed treatments documented over several months. One resident's wound was not assessed for weeks, and another resident's wound care was improperly conducted by an LPN. The DON confirmed these findings.
The facility failed to provide physician-ordered nutritional supplements to two residents at nutritional risk. One resident, with a history of skin breakdown, did not receive Boost as prescribed, leading to a small open area on the scrotum. Another resident, with an open wound, experienced significant weight loss due to the unavailability of Boost. Staff confirmed supply issues, acknowledging the deficiency.
The facility failed to maintain a clean and safe environment in the Ivy Nursing Unit and dining room. Observations revealed stains, debris, and maintenance issues in the dining room and shower room over two days. These findings were discussed with the Nursing Home Administrator and DON.
A resident with osteoarthritis and mobility issues did not receive the recommended restorative nursing program after discharge from physical therapy. The care plan required daily ambulation with assistance, but documentation showed the task was not completed on several occasions. Staff interviews revealed confusion about documentation and inconsistent implementation of the program.
A facility failed to provide adequate care for a resident with a PICC line and pacemaker. The facility lacked a policy for PICC line care, had no signage to prevent improper use of the resident's arm, and did not have emergency supplies available. The resident's care plan did not address their bacteremia, intravenous antibiotics, PICC line, or pacemaker. Observations confirmed the absence of necessary precautions and equipment for pacemaker monitoring.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the main kitchen and on one nursing unit, Sage. In the main kitchen on May 18, 2026, the cook’s refrigerator contained onions and peppers, tomato soup, and a turkey roast dated May 11, 2026. A rack of loaves of bread and bags of buns had no receive date or expiration date, and Employee 19 confirmed the bags had been removed from the freezer but had not been dated. The dishwasher unit also had a metal box beneath it with thermal tape coating that was bubbling and peeling around the unit. On Sage unit on May 20, 2026, the pantry sink area had dried brown liquid on the counter, a bulging and rippled wooden cupboard finish from water contact, and dried brown and red splashed substance on the wall near the ceiling. The condiment tray contained an open container of sugar free breakfast syrup with a saturated pepper packet stuck to it and crystallized syrup in the tray. The refrigerator contained a bag of grapes dated May 9, 2026, with grapes that were brown and wrinkled, and the top of the refrigerator was covered in dust. The ice machine drainage tube was looped with a black substance visible in the clear tubing, no drain or air gap could be visualized, and behind the ice machine a Styrofoam cup held water from what appeared to be a leak in a tube. A plastic spoon and plastic lid were visible under the ice machine. The information was reviewed with the Nursing Home Administrator on May 21, 2026.
Inadequate Monitoring of Psychotropic Medication Regimens
Penalty
Summary
The facility failed to ensure that the medication regimens for two residents were free from potentially unnecessary psychotropic medications and were adequately monitored for behavioral symptoms and adverse effects. The cited policy identified antidepressants and antipsychotics as psychotropic medications requiring interdisciplinary evaluation, monitoring for efficacy and adverse consequences, and review of whether gradual dose reductions were appropriate. Surveyors reviewed the records of two residents and found that the required ongoing monitoring was not documented in the MAR/TAR for either resident during the months reviewed. For one resident admitted with a history of depression and anxiety, the record showed multiple changes in Fluoxetine dosing over several months, including increases and decreases between 20 mg, 40 mg, and 60 mg daily. The resident reported a tremor that sometimes limited shaving and holding a cup, and the physician documented communication with the contracted psych provider about whether Fluoxetine could be reduced because of the increased tremor. The psychiatry provider noted concern that the tremor may have been related to the Prozac titration or Gabapentin and agreed to return the resident to 40 mg. Social services documentation also recorded severe depression with PHQ-9 scores of 24 and 27 and statements that the resident felt he would be better off dead every day. Despite these findings, the MAR/TAR for March, April, and May 2026 did not show ongoing monitoring of negative behaviors related to depression or potential adverse effects from the antidepressant. For the other resident, the active orders included Sertraline 100 mg nightly, Sertraline 25 mg at bedtime, Trazodone 50 mg every evening, and Risperdal 3 mg twice daily. The facility had initiated behavior monitoring for anxiety and aggressiveness, but review of the MAR/TAR for March, April, and May 2026 showed no ongoing monitoring of negative behaviors related to the resident’s depression diagnosis. The deficiency was confirmed by the DON, and the cited regulation was 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Follow Ordered Interventions and Restrictions
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered interventions for three residents. Resident 30 had an active order dated February 6, 2026, to wear tubigrips to both lower extremities every day, but the care plan did not include that intervention. Although the MAR/TAR showed staff initialed application of the tubigrips in the morning, observations on May 19 and May 21, 2026, showed Resident 30 without compression garments and with swollen lower legs and ankles. Resident 30 stated he did not know he was supposed to wear compression garments and later said he was not wearing any because he had not gotten them yet. Resident 5 was observed with ace wraps on both lower extremities, with the wrap on the right leg unwinding and rolled, yet the clinical record contained no physician order for ace wraps and the care plan did not include them. Podiatry documentation noted absent dorsalis and posterior tibial pulses, nail thickening, callus, dry skin, and lower extremity edema, and included a consult with the PCP regarding diuretics and compression therapy. Resident 3, who had diagnoses including chronic CHF and CKD, had a physician order for a 1500 mL fluid restriction with intake to be documented in POC, but observations showed multiple cases of water and empty beverage containers in the room. POC documentation recorded daily fluid totals above the ordered restriction, and the nutritional risk assessment did not address noncompliance or document that staff educated Resident 3 about the consequences of not following the restriction.
Failure to Develop Person-Centered Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss for two residents reviewed. Resident 74 was admitted with a diagnosis of dementia, and her admission MDS dated August 29, 2025, indicated the facility assessed her as having dementia and determined that a care plan for dementia and cognitive loss would be developed. However, review of her care plan showed no indication that a person-centered care plan had been developed or implemented to address her dementia and cognitive loss. Resident 10 was admitted with a diagnosis of dementia, and her annual MDS indicated that the facility assessed her as having dementia and determined that a care plan for dementia and cognitive loss would be developed. Review of her care plan also showed no indication that the facility had developed or implemented an individualized person-centered care plan to address her dementia and cognitive loss. A social worker confirmed these findings during interview, and the DON was unable to provide additional documentation showing that such care plans had been developed and implemented for either resident.
Infection Control Failures With Precautions, Hand Hygiene, Laundry, and Water Management
Penalty
Summary
The facility failed to implement transmission-based precautions and Enhanced Barrier Precautions as ordered for multiple residents. Resident 2 had an active physician order for Enhanced Barrier Precautions related to a surgical incision on the back, and the room had signage and PPE supplies posted at the door. During wound care, an LPN removed the dressing and reapplied a dry dressing without donning a gown, even though the resident required gown and glove use for high-contact care. The same resident reported having recent back surgery and a surgical incision at the time of the observation. The facility also failed to follow contact precaution requirements for two residents with infectious conditions. Resident 69 had MRSA to an open abdominal area and was on contact precautions, with signage at the door directing staff to clean hands and wear gown and gloves before entry. Despite this, a nurse aide delivered the meal tray without gown or gloves. Resident 35 had C. difficile and was also on contact precautions, with signage and PPE supplies posted outside the room. Staff were observed entering and exiting the room without hand hygiene and without gown and glove use, including an RN and nurse aides who handled laundry, supplies, and a Hoyer lift while moving in and out of the room. The facility failed to maintain hand hygiene practices and laundry handling practices consistent with its policies. During medication administration for Resident 81, an LPN changed gloves but did not perform hand hygiene between glove changes and again did not perform hand hygiene after removing gloves before documenting on the medication cart computer. In the laundry department, soiled resident laundry was opened and emptied into washers, staff removed gloves and walked to a hallway bathroom to wash hands, and a sink near the washers was covered and not being used. Staff also reported uncertainty about washer load limits, and the laundry scale was found in the corner of the room with brooms and a dustpan on it rather than being used for weighing loads. The facility also did not have an individualized water management program for waterborne pathogens such as Legionella. The facility provided a CDC checklist rather than a facility-specific program, and staff reported that the building had no water holding tanks and city water entered directly to the hot water heaters. The facility did not provide a schematic identifying problem areas or a documented program with identified risks, control measures, monitoring protocols, acceptable outcomes, or actions to take when control limits were not met. Available Legionella policies referenced potential risk areas such as water storage tanks, heaters, filters, and fountains, but did not specify control measures, monitoring limits, or response steps.
Failure to Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure residents were offered pneumococcal immunization unless medically contraindicated for three of five residents reviewed for immunizations. The facility policy stated that residents would be assessed for pneumococcal vaccine eligibility prior to or upon admission and offered the vaccine series within 30 days unless contraindicated, with administration to follow current CDC recommendations. Current CDC guidance cited in the report identified multiple pneumococcal vaccine options, including PCV15, PCV20, PCV21, and PPSV23, and described age- and history-based timing for adults. Resident 30 was admitted after having received Prevnar13 more than 10 years earlier, and the record contained no evidence of any additional pneumococcal vaccinations despite consent from the resident’s daughter for pneumococcal vaccine. Resident 54 had no documented pneumococcal immunizations before admission and consented to vaccination, but the facility administered PPSV23 even though CDC guidance indicated PCV15, PCV20, or PCV21 should have been given. Resident 22 had received Prevnar13 and PPSV23 before admission, consented through her daughter, and was documented as not eligible for PCV20 on one date; however, the record showed she became eligible for a pneumococcal revaccination later and there was no evidence the facility offered it when she became eligible. The DON confirmed these findings during interview.
Failure to Document and Offer COVID-19 Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 immunization unless contraindicated for four of five residents reviewed for immunizations. Resident 5 was admitted on November 6, 2024, and a COVID-19 Booster Consent or Refusal form signed on October 20, 2025, showed that the resident's daughter gave verbal permission for the vaccine, but the clinical record did not contain evidence that the vaccine was administered. Resident 22 was admitted on July 29, 2020, had a COVID-19 vaccine documented on August 2, 2024, and a later Booster Consent or Refusal form showed verbal permission from the resident's daughter, but the record did not contain evidence of any COVID-19 vaccine after August 2024. Resident 30 was admitted on March 28, 2025, had a Booster Consent or Refusal form showing verbal permission from the resident's daughter, but no evidence of a COVID-19 immunization in the clinical record. Resident 54 was admitted on August 22, 2024, had a Booster Consent or Refusal form showing the resident consented to receive the vaccine, but the clinical record did not contain evidence that the vaccine was given. The facility also failed to maintain documentation related to staff COVID-19 vaccination status. The facility policy on Coronavirus Disease (COVID-19), Infection Prevention and Control Measures, stated that the facility follows CDC-recommended infection prevention and control practices and includes encouraging staff, residents, and visitors to remain up to date with COVID-19 vaccine doses and providing resources and counseling about the importance of receiving the vaccine. However, facility policies did not indicate that staff vaccination status would be documented. The DON stated in interview that the facility had no evidence of documentation regarding staff COVID-19 immunization status and that, although staff are asked upon hire to provide an immunization card or other documentation, the facility had no practice of offering or documenting staff COVID-19 immunizations after that time.
Failure to Protect Resident Dignity
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for two residents. One resident stated during an interview that she frequently preferred to keep her door closed and that staff often did not knock before entering her room. While she was being interviewed, a housekeeping employee was observed opening her closed door without knocking and entering the room to deliver laundry. After the employee left, the resident stated, "See? They never knock," reflecting the observed failure to respect her private space. A second resident had a physician order dated November 11, 2025, for care of nephrostomy tubes. On May 19, 2026, the resident was observed sitting across from the nurse's station with a urinary catheter bag resting on their lap and appearing half full of yellow liquid. Later, staff stood the resident up and clipped the urine bag to the outside of the resident's pants to assist with ambulation to the dining room. The resident was then observed in the dining room with urine bags wrapped around the front arm support of the chair while eating lunch, and later ambulating down the hallway with two urine bags, one clipped to each side of the shirt, both filled with yellow liquid.
Failure to Assess Self-Administration Capability
Penalty
Summary
The facility failed to determine whether Resident 3 was capable of self-administering medications. The resident was admitted on September 3, 2025, and had a physician order, initiated April 9, 2026, for staff to administer Voltaren Arthritis Pain External Gel topically to the right elbow, shoulder, and left hand twice daily for pain. The facility policy stated that residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, with the decision documented in the medical record and care plan after assessment of cognitive and physical abilities. On May 18, 2026, a surveyor observed Resident 3 at the nurses' station when an LPN handed the resident a souffle cup containing an unidentified white substance, which the resident carried to his room. Later that morning, the resident stated the substance was his ordered Voltaren gel and that he would apply it to his shoulder later. Review of the clinical record found no evidence of an assessment for self-administration. The NHA and DON confirmed on May 21, 2026, that the facility had not assessed Resident 3's capability to self-administer the Voltaren gel, and the DON stated a Medication Self-Administration Screen was completed after surveyor questioning and determined the resident was unable to safely administer medications.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to ensure that personal fund statements were provided quarterly to the resident or the resident’s responsible party for two residents whose money was held by the nursing home. For one resident, the daughter served as financial and healthcare POA, substitute decision-maker, and resident representative, and she stated she did not receive a quarterly statement even though the facility held her mother’s money. The resident’s record showed severe cognitive impairment, including being rarely or never understood, having long- and short-term memory problems, and having severely impaired cognitive skills for decision making. A handwritten note on the resident fund statement stated that the resident gets her own and did not send to POA. For the second resident, the resident stated that the facility business office held her money but that she did not receive a statement at least quarterly and did not know who received it. The resident’s MDS showed a BIMS score of 15 with no cognitive impairments. The business office manager stated that quarterly statements were printed and placed in the activities box for the activities director to deliver, and the activities director said she hand-delivered the statements in her box but could not recall which residents received them and could not recall whether she delivered a resident fund statement to this resident.
Housekeeping and Maintenance Deficiencies on Ivy Unit
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on the Ivy unit, including the rooms and bathroom of two residents. Observation of one resident’s room revealed a strong urine-like odor, a pile of linens in a soiled linen bag with some linens on top of the bag, and later the room continued to have a strong urine-like odor with the floor remaining sticky underfoot. During interview, the resident stated she is incontinent of bladder, frequently urinates on the floor, cleans it herself, and places soiled linens on the floor to be collected later. A housekeeping employee was observed entering the room and commenting that the floor was not as sticky as before. Observation of another resident’s bathroom revealed a sticky floor and a counter behind the faucet that was yellow and appeared stained; the resident stated housekeeping cleans the bathrooms about once a week. Observation of the wall across from the nursing station on the Ivy unit also showed paint scraped off the handrails, exposing bare metal.
Failure to Communicate Resident Representative Information During Hospital Transfer
Penalty
Summary
The facility failed to ensure that resident representative contact information was communicated to the receiving health care institution for one resident transferred to the hospital. Clinical record review showed the resident told nursing staff on April 22, 2026, at 6:40 PM that he wanted to go to the emergency room because of back pain, and 911 transported him by stretcher. Nursing documentation stated that the resident’s sister was made aware of the transfer, and the clinical profile listed the sister as the resident’s representative. However, the eINTERACT Transfer Form completed for the hospital discharge identified the resident as his own representative and did not include the sister’s contact information. The DON confirmed that the eINTERACT Transfer Form was the facility’s method for communicating information to hospital staff and that the form did not communicate the resident representative contact information.
Inaccurate MDS Fall Injury Coding
Penalty
Summary
The facility failed to ensure that a resident assessment accurately reflected Resident 2’s status. Clinical record review showed that on April 22, 2026, Resident 2 was found on the floor and complained of mid back pain. Later that day, Resident 2 insisted on going to the emergency room because of the back pain and was transported by 911. The next day, nursing documentation noted that the hospital reported Resident 2 had been admitted for vertebral fractures and was going to have surgery. A Discharge MDS dated April 22, 2026, coded the fall as an injury that was not a major injury, and facility staff signed the assessment section on April 24, 2026. However, the hospital discharge summary for the April 22 to April 27, 2026 hospitalization identified the principal diagnosis as a fall with a T7-T8 unstable fracture, and the resident underwent surgery. The RAI manual instructions cited in the report define major injury to include traumatic bone fractures and spinal cord injuries, and the surveyor confirmed the MDS injury coding error with the Nursing Home Administrator.
Failure to Include Daily Tubigrip Use in Care Plan
Penalty
Summary
The facility failed to revise Resident 30’s plan of care to include an active physician’s order for tubigrips to be worn on both lower extremities every day. Clinical record review showed the order was dated February 6, 2026, and observation on May 19, 2026, at 10:22 AM found the resident’s lower legs and ankles swollen and the resident not wearing tubigrips. Review of the resident’s care plans showed no intervention addressing daily tubigrip use to the bilateral lower extremities. The MAR/TAR for May 2026 showed staff initials documenting application of the tubigrips in the morning, and the concern was reviewed with the NHA and DON on May 21, 2026, at 11:08 AM.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance to a dependent resident who was assessed as totally dependent on staff for bathing. Resident 48 was observed in bed on May 18, 2026, and again on May 19, 2026, with hair that appeared greasy. During interview on May 19, 2026, the resident was unable to recall when she last received a shower and stated she was supposed to receive a shower once a week. Her clinical record showed she was admitted on September 3, 2025, and her most recent MDS dated March 27, 2026, identified her as dependent on staff for bathing. Resident 48’s plan of care, initiated September 3, 2025, documented an ADL self-care performance deficit and that she was totally dependent on staff to provide a bath or shower weekly and as necessary. Her ADL task documentation listed a preference for a shower every Thursday evening. However, the documentation survey report for March, April, and May 2026 showed only four showers/baths and two refusals. There was no documentation that staff offered a shower or that Resident 48 refused one from May 1 to 21, 2026. The findings were reviewed with the NHA and DON on May 20, 2026, and the DON later stated she was unable to provide further documentation that bathing assistance had been provided.
Failure to Implement Fall-Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for two residents reviewed for falls. For Resident 37, clinical record review showed a fall without injuries in the shower on February 13, 2026. The interdisciplinary team determined that non-slip strips should be added to the resident’s shower and that the care plan would be updated to reflect this intervention, but observation of the shower on May 20, 2026, found no non-slip strips present. An interview with an aide confirmed that the resident did not have non-slip strips in the shower and that none were installed in the unit’s shower area. The Nursing Home Administrator was informed of these findings and confirmed that non-skid strips are strips directly adhered to the floor. For Resident 8, the care plan initiated on November 14, 2025, identified the resident as at risk for falls and included an intervention for a “Call don’t Fall” sign to be hung in the room. However, observation of the room on May 20, 2026, showed no such sign anywhere in the room. The resident stated they did not recall ever having a sign hung in the room, and an LPN later confirmed that no sign was hanging in the room related to falls or the call bell. The Nursing Home Administrator was informed of these findings on May 21, 2026.
Lack of documented nursing competencies for specialized resident care
Penalty
Summary
Nursing staff competencies were not available for two registered nurses for the care and assessment of residents who use a lift, wound vac, PICC line, catheter care, medication administration, and dressing changes. The facility documentation showed 70 residents receiving medications, 12 residents using lifts, one resident with a wound vac, five residents with indwelling urinary catheters, 11 residents with dressing changes, one resident receiving IV therapy, and one resident with a PICC line. A request for nursing staff competencies for medication administration, lifts, wound vac, catheter care, dressing changes, IV therapy, and PICC line care showed the facility could not provide any competencies for Employees 5 and 6 in the last year. The findings were reviewed with the NHA and DON, and the DON later confirmed there was no documentation showing that these two RNs had specific competencies and skill sets to care for the residents' listed needs.
Failure to Address Pharmacy Recommendations and Monthly Drug Review
Penalty
Summary
The facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for two residents reviewed. The consultant pharmacist's reports were to be made available to nurses, physicians, and the care planning team, with recommendations communicated in a timely fashion and acted upon and documented by facility staff and/or the physician. For one resident, a pharmacy review requested that the physician add instructions to mix polyethylene glycol into 4 to 8 ounces of fluid, but the physician did not address the recommendation until more than two months later. For another resident, a pharmacy recommendation requested an appropriate diagnosis for prescribed Klonopin, but there was no evidence that the facility staff and/or physician addressed it. A later pharmacy recommendation noted the resident was receiving atorvastatin, magnesium, and Depakote and requested lab monitoring with results available for review, but there was no evidence that the recommendation was addressed or that the requested labs were obtained. The facility was also unable to provide documentation that the pharmacy completed a monthly review for March 2026.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for two residents reviewed for dental concerns. Resident 22’s record showed an annual MDS assessment identifying obvious or likely cavity or broken natural teeth, and the dental CAA triggered a care plan. The care plan, initiated on November 13, 2023, included obtaining dental consultation as necessary. The resident’s record contained documentation from the facility’s consultant dentist dated April 10, 2025 and from the consultant dental hygienist dated February 9, 2026, but the DON and NHA stated on May 21, 2026 that there was no further evidence of professional dental services provided twice a year as covered under the State plan for Resident 22. Resident 22’s daughter stated that the resident had bad natural teeth and that she was not opposed to services from the facility’s contracted dental provider. Resident 3 was observed edentulous and stated he had not been offered a dentist since admission. He also stated he had dentures at home that did not fit correctly. The resident was admitted on September 3, 2025, and the admission MDS assessed no obvious or likely cavity or broken natural teeth. The care plan, initiated September 9, 2025, identified risk for altered dentition and/or mucous membranes related to edentulous status and noted that the resident did not wear dentures, with an intervention to obtain dental consultation as necessary. The facility was unable to provide documentation that dental services were offered to Resident 3, and the NHA confirmed these findings.
Inaccurate Clinical Documentation After Resident Death
Penalty
Summary
The facility failed to ensure an accurately documented clinical record for one resident whose closed record was reviewed. The resident was discharged on April 14, 2026, and nursing documentation from that evening recorded that the resident was without response to verbal stimuli, without respirations, and without heart sounds, with the nurse documenting the time of death as 9:30 PM. Another nursing entry later that night documented that the funeral home removed the resident’s body from the facility at 11:32 PM. However, physician discharge documentation entered at 11:54 PM on the same date included care plan comments about encouraging a low salt diet and moderating fluids, noting the resident was otherwise fairly stable fluid status at that time. The discrepancy in the record was reviewed with the NHA and DON during the survey.
QAPI Committee Failed to Meet Quarterly and Lacked Required Member
Penalty
Summary
The facility failed to ensure the QAPI committee met at least quarterly and included the required minimum members, specifically the Infection Preventionist. Review of QAPI meeting attendance records dated August 26, 2025, through April 30, 2026, showed that no meeting was held during the first quarter of 2026, with meetings documented on December 30, 2025, and again on April 30, 2026. The April 30, 2026 attendance record also showed that the Infection Preventionist did not attend the meeting. The Nursing Home Administrator confirmed these findings during interview on May 21, 2026, at 11:03 AM.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post and retain daily nurse staffing information for the past 18 months at two nursing stations, Ivy and Sage. On observation of the facility on May 18, 2026, at 2:12 PM and May 19, 2026, at 5:09 PM, there was no evidence that nursing staffing hours for the day were posted in the facility. Review of the facility’s daily nurse staffing postings for April and May 2026 showed multiple missing postings across numerous dates and shifts, including missing first, second, and third shift postings on several days. The Director of Nursing confirmed these findings during an interview on May 21, 2026, at 11:03 AM.
Lack of Qualified Dietary Leadership
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. During an interview, the registered dietitian confirmed she was only employed at the facility three days a week and not on a full-time basis. At the same time, the dietary manager stated she did not possess certification as a dietary manager, food service manager, or any national certification for food service management and safety, nor did she hold a degree in food service management. Further confirmation from the Nursing Home Administrator established that the facility did not have a full-time qualified dietitian or a qualified director of food and nutrition services. The report does not mention any specific residents or their conditions in relation to this deficiency. The findings are based on staff interviews and direct confirmation from facility leadership.
Plan Of Correction
1. Facility is unable to retroactively correct past deficiency. 2. Employee #1 has been enrolled in the "ServeSafe for Managers" course. 3. Administrator will be educated on Qualified Dietary Staff Requirement. 4. Administrator/Designee will audit Employee #1's progress in "ServeSafe for Managers" course weekly x4 weeks to ensure timely completion. Results will be forwarded to QA committee. F 0801
Food Storage and Sanitation Deficiencies in Kitchen and Nursing Units
Penalty
Summary
The facility failed to maintain food service equipment and store food in a sanitary manner in the main kitchen and two nursing units, Sage and Ivy. Observations in the main kitchen revealed that the interior of the steam table water wells had a buildup of brown film and significant food debris, including vegetables and potatoes, floating in the water after breakfast service. In a two-door cooler, plastic bins containing cups of milk were found uncovered and undated. The ceiling over the dish room area had multiple rust-colored spots, a pipe near the ceiling was covered in visible dust, and the light covers were dirty with blackened areas and dried food splatter. The walk-in freezer had large chunks of ice on the floor behind the condenser, and the lower freezer shelves were lined with porous wood, which presented a risk for harboring bacteria. The dry storage area also had lower shelves lined with porous wood, some with dried liquid stains. On the Sage nursing unit, the pantry had a buildup of dust, debris, and dried spills on the floor, and a large garbage can with dried food splatter on its exterior. The wall behind and beside the garbage can was covered in dried food splatter from three feet up the wall to the floor. The refrigerator in the Sage pantry was soiled on the interior base and the lower vent unit was dusty and dirty. In the Ivy nursing unit pantry, the flooring was blackened and dirty, and the interior of a single door cooler had dried purple liquid on its base. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
All areas identified during survey regarding cleanliness were corrected. The uncovered cups of milk in the cooler were discarded at the time of the survey. The shelves have been replaced with a non-porous shelf. The lower shelves that were using wood were removed and replaced with a non-porous material. The floors of both pantries were cleaned. Food Service Director and Administrator will conduct an audit of general cleanliness standards of the kitchen to ensure no other cleanliness issues are present. Food Service Director and dietary staff will be educated on general cleanliness standards of the kitchen. Housekeeping, Dietary Staff, and Nursing will be educated on cleanliness of the pantries. Maintenance will be educated on cleaning the dust in the ceiling and kitchen ceilings will be added to a cleaning schedule. Daily cleaning checklists for each dietary shift will be updated, and dietary supervisor cleaning list was updated and will be signed off at the completion of shift. Weekly cleaning checklists will be implemented and signed off by FSD and submitted to the Admin. Nursing home administrator/designee will conduct random audits of kitchen areas daily x4 days a week for two weeks and then weekly times two months. Results will be reviewed during the monthly QAPI meeting to ensure ongoing compliance.
Failure to Protect Resident Privacy Due to Use of Personal Electronic Devices
Penalty
Summary
Staff at the facility failed to ensure the privacy and confidentiality of resident medical records by allowing the use of personal electronic devices to access and document resident information. During medication administration, an LPN was observed using her own personal device to access a resident's medical record, citing a lack of available facility-supplied devices as the reason. The LPN confirmed that she brought her own device from home to ensure timely access to resident records for medication administration and documentation. Further observations and staff interviews revealed that other staff members, including nurse aides, also brought personal electronic devices into the facility for the purpose of accessing and documenting in resident records. At the time of the survey, there were not enough facility-supplied laptops and iPads available for the number of staff on duty, leading to the use of personal devices. Facility documentation confirmed that staff had received training on HIPAA, confidentiality, and resident rights, which included the requirement to keep resident information private. Despite this training, the facility was unable to ensure the security of resident personal and private information due to the use of personal devices for accessing clinical records. The lack of sufficient facility-supplied electronic devices directly contributed to this deficiency, as staff resorted to using their own devices to fulfill their duties. The facility's inability to provide adequate equipment resulted in a failure to protect resident privacy and confidentiality as required by federal and state regulations.
Plan Of Correction
1. Facility is unable to retroactively correct staff members using personal computers for documentation purposes. 2. Staff were provided additional facility-issued laptops/POC documentation devices. 3. Administrator checked the status of laptops previously ordered and expected delivery date. Additional laptops were also purchased; unused facility laptops/desktops were provided to nursing units. All nursing staff will be re-educated on HIPAA/only using facility-provided computer equipment. 4. Random audits will be conducted to ensure only facility-issued computers are being used, 2x a day, 3x a week, then weekly for 4 weeks. Administrator/designee to ensure compliance. Results of the audits will be presented at the QAPI meetings for review and to ensure ongoing compliance. F 0583
Failure to Follow Physician Orders for Aspira Catheter Care
Penalty
Summary
The facility failed to ensure that physician-ordered interventions and treatments for a resident with an Aspira catheter were carried out according to professional standards and the care plan. Physician orders specified that only RN staff were to drain the Aspira catheter every other day on day shift, not to exceed 1000 ml per session, and to document the output, color, and character of the drainage. Additionally, only RN staff were to change the catheter dressing every other day and the connecting valve weekly. However, clinical record review revealed multiple dates where there was no documentation that RN staff performed these tasks. Instead, LPN staff documented completion of the catheter drainage and dressing changes on several occasions, contrary to the physician's orders. Further review showed that only RN staff received education on the management of Aspira catheters, with no documentation of similar education for LPN staff. The lack of proper documentation and adherence to physician orders was confirmed during an interview with the Director of Nursing. These findings indicate that the facility did not provide care in accordance with the prescribed orders and professional standards for the resident with the Aspira catheter.
Plan Of Correction
1. Resident 67 has discharged from the facility. 2. An audit of the last 14 days was completed of any other Aspira Catheter Drains or chest tubes in the facility, and it was confirmed that LPNs were not providing valve changes or dressing changes. 3. All LPN staff will be educated, and competency will be completed related to Chest Tubes and Chest Tube Management. All licensed staff will be educated on proper documentation in the electronic medical record. 4. Audits will be conducted by the DON/Designee of any resident with a chest tube to ensure all physician orders related to the same are being followed for dressing changes and documentation. These audits will occur four times a week daily, weekly for four weeks, and monthly for two months. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.
Failure to Maintain Consistent Advance Directives
Penalty
Summary
The facility failed to establish clear and consistent advance directives for one resident. Clinical record review showed that the resident had a physician's order dated May 28, 2025, indicating a DNR (do not resuscitate) status, meaning no CPR should be performed if the resident had no pulse and was not breathing. However, a POLST (Pennsylvania Orders for Life Sustaining Treatment) form dated May 7, 2025, and signed by the resident, indicated that the resident desired to be a full code, meaning CPR should be attempted under the same circumstances. There was no documented evidence that the resident completed an updated POLST after May 7, 2025, nor was there any documentation of discussions with facility staff or the physician indicating a change in the resident's wishes regarding life-sustaining treatment. This lack of documentation and clarity regarding the resident's advance directives was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Resident 28's Advanced Directive was immediately clarified with resident and signed by MD. Information was updated in resident orders, special instructions, and Care Plan. Resident 28's Advanced Directive was uploaded into electronic medical record. 2. An audit of all residents' POLST was completed to ensure resident order, special instructions, and Care Plan matched wishes expressed on signed POLST form. 3. All new or amended POLST forms will have an order immediately entered in PCC. Care Plan and special instructions will be updated. Any new/amended POLST will be uploaded to the "Document" tab in residents' electronic medical chart. All Licensed Staff will be educated on immediately entering/amending order, special instructions, and Care Plan based on POLST form. All existing resident POLST will be uploaded into residents' electronic record. 4. Audits will be conducted of any admissions or updated POLST, daily 4x a week, weekly for 4 weeks, and monthly x2 by the Administrator/designee to ensure compliance. Results of the audits will be presented at the QAPI meetings for review and to ensure ongoing compliance.
Failure to Maintain Clean and Homelike Environment on Nursing Unit
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment on one of its nursing units. Specifically, in the rooms of two residents, there was visible damage to the walls next to the bathroom doors, with 10 to 12 inches and 2 inches of exposed drywall paper, respectively. In both cases, a hand sanitizer dispenser was installed, partially covering the damaged areas. Additionally, the hallway on the same unit had a painted handrail with the paint worn off, exposing the underlying metal, particularly at the intersection near the nursing station. Further observations included dried brown liquid splatter on the lower portion of the wall behind two medication carts across from the nursing station, and a vent above the nursing station with visible dust hanging on both the interior and exterior, extending to the surrounding ceiling tiles. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Any dried liquid observed on the lower portion of the wall behind Med Carts was cleaned the day of survey. The vent above Sage Nursing Station was cleaned the day of survey. Resident 27's and Resident 66's wall next to the bathroom door has been fixed, under the hand sanitizer dispenser. The handrails have been painted on Sage Hallway. 2. A whole house room audit was completed to identify any other resident rooms that drywall is exposed. A whole house audit was also completed to ensure no vents had a buildup of dust, and no walls had dried liquid present. 3. Areas that drywall is exposed will be fixed, vents and walls will be cleaned to ensure a clean, home-like environment. Housekeeping and Nursing staff will be educated to ensure walls are clean. Maintenance Staff will be educated on fixing exposed drywall, painting hand rails when metal is exposed and maintaining clean vents. 4. Environmental audits will be conducted of the Sage Hallway/Nursing Station, daily 4x a week, weekly for 4 weeks and monthly x2 by the Administrator/designee to ensure compliance. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement required fall prevention interventions for two residents who were assessed as being at risk for falls. For one resident with diagnoses including unsteadiness, dementia, gait abnormalities, and muscle weakness, clinical records and care plans indicated the need for a chair alarm to be in place and checked every shift. Despite this, observations on multiple occasions revealed that the resident was mobile in a wheelchair without the chair alarm attached, as it was found hanging on the dresser instead. Staff confirmed that the alarm should have been in use and subsequently placed it on the wheelchair after being notified. For another resident, a physician's order required the use of a chair alarm and regular checks for its placement and function. However, repeated observations showed the resident seated in a wheelchair without the alarm in place. Staff interviews confirmed the absence of the alarm during these times. These failures to follow physician orders and care plan interventions for fall prevention were confirmed through staff interviews and review of clinical documentation.
Plan Of Correction
1. Resident 7 and 46 immediately had a chair alarm added the day of the survey. 2. A whole house audit was completed on all residents who are ordered/CP'ed to have a chair alarm to ensure placement in wheelchair, and that the chair alarm is listed in Kardex. 3. All residents who have an order/or CP'ed as a fall intervention will have a chair alarm in place when in a wheelchair. All nursing staff will be educated to ensure the chair alarm is in place when the resident is in a chair. All CNAs will be educated to check Kardex if a chair alarm is needed for safety. 4. Random resident audits will be conducted of residents requiring a chair alarm, daily 4x a week, weekly for 4 weeks, and monthly x2 by the Administrator/designee to ensure the chair alarm is in place and in working order. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.
Failure to Implement Enhanced Barrier Precautions During High-Contact Procedure
Penalty
Summary
A deficiency was identified when a registered nurse failed to implement Enhanced Barrier Precautions (EBP) during a high-contact procedure for a resident with indwelling medical devices. Specifically, during a chest tube dressing change, the nurse donned gloves but did not wear a gown as required by EBP protocols. The resident had both a urinary Foley catheter and a chest tube, and there was an active physician's order for EBP due to these devices. An enhanced barrier sign was posted outside the resident's room, indicating the need for these precautions. The observation was made during a dressing change, where the nurse removed the old dressing, cleansed the area, changed gloves, and applied a new dressing without donning a gown. The failure to use a gown during this high-contact activity was contrary to the requirements outlined in the CMS memo on EBP, which mandates gown and glove use for residents with indwelling devices during such procedures. The deficiency was confirmed through observation, clinical record review, and staff interviews.
Plan Of Correction
1. Facility is unable to retroactively correct staff member entering room to give high-contact care with incorrect PPE. 2. An audit of all residents on EBP was completed to ensure proper signage to include proper PPE required. 3. All nursing staff will be educated on EBP, including what PPE is required and when it is required. 4. Administrator or designee will complete a random audit of residents on EBP 4x a week for 4 weeks and weekly for 2 months to ensure proper PPE is being used and at the correct times. Results will be reviewed by QAPI committee for further action planning as necessary.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman upon the transfer of multiple residents to the hospital. Clinical record reviews for several residents revealed that, following changes in their conditions, they were transferred and admitted to the hospital. However, there was no documentation that the required written notification was provided to the State Ombudsman regarding these transfers. This deficiency was identified for nine out of ten residents reviewed for hospitalizations. Specific examples include residents who were sent to the hospital due to chest pain, changes in condition, or for re-evaluation, with subsequent documentation confirming their admission to the hospital. Despite these transfers, the records lacked evidence that the Ombudsman was notified as required by federal regulations. Interviews with the Nursing Home Administrator confirmed that notifications to the Ombudsman were not being sent for hospital admissions. The surveyor reviewed these findings with the Nursing Home Administrator, who acknowledged that the facility did not send notifications for hospital admissions. The lack of documentation and notification was consistent across multiple cases, indicating a systemic failure to comply with the regulatory requirement to inform the State Ombudsman of resident transfers to the hospital.
Plan Of Correction
1. The State Long Term Care Ombudsman will be notified via email of the transfers of Residents 13, 23, 26, 28, 50, 55, 57, 64, and 66. 2. NHA/designee will audit the facility-initiated transfers for the last 30 days to ensure that the Office of the State Long-Term Care Ombudsman was notified. 3. Social Service Director/designee will maintain a log of residents transferred from the facility. Monthly, the NHA/designee will audit the log to ensure compliance, and SSD will submit the log to the Office of the State Long-Term Care Ombudsman. The date of notification will be recorded on the audit form. 4. All hospital transfers will be reviewed in AM meeting 4x a week for 4 weeks, and weekly x2 months to ensure written notification was provided to the State Long Term Care Ombudsman. Results of the audits will be presented at the Quality Assurance Performance Improvement meetings for review and to ensure ongoing compliance.
Failure to Include Required Disciplines in Infection Control Committee
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements outlined in the Act 52 Infection Control Plan. Specifically, the facility did not include representatives from pharmacy or laboratory personnel in its infection control committee meetings, as required by regulation. Documentation provided by the facility, titled "QAPI (Quality Assurance and Performance Improvement) Attendance," was reviewed for several meeting dates, but there was no evidence or signatures indicating that pharmacy or lab staff attended any of these meetings. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that infection control meetings were held during QAPI meetings on a quarterly basis or more frequently if needed. However, attendance records for these meetings did not show participation from pharmacy or laboratory personnel, which is a required component of the multidisciplinary infection control committee. No information about specific residents or their medical conditions was included in the report.
Plan Of Correction
1. Facility is unable to retroactively correct deficiency for past Act 52 meetings. 2. An employee of the Pharmacy and a Representative from the Laboratory have been invited to the next QA/Act 52 meeting. 3. All attempts will be made to ensure all appropriate members are present and will facilitate via phone conference if necessary. The Administrator and DON will be educated on which members of the multidisciplinary committee need to be present for QA/Act 52 meetings. 4. Monthly sign-in sheets for QA/Act 52 will be reviewed to ensure all appropriate members of QA/Act 52 meeting was present monthly and results will be forwarded to QA meeting to ensure ongoing compliance.
Failure to Verify Nurse Aide Competency in Resident Care Skills
Penalty
Summary
The facility failed to ensure that nurse aide staff possessed and demonstrated the specific competencies and skill sets required for safe resident care, particularly regarding transfer techniques. Documentation review for three nurse aides showed that while staff completed and signed off on various competency worksheets and attended in-service education, there was no evidence that the facility evaluated their knowledge or skills through return demonstrations or direct observation. In one case, a nurse aide's record lacked the required CNA Competencies worksheet, and in another, the documentation did not include attestation by another staff member confirming the aide's demonstration of skills. For a newly hired aide, orientation records indicated only acknowledgment of training topics, without any verification of competency through demonstration. Interviews with the LPN responsible for nurse aide competency training revealed that the process consisted of providing information packets and obtaining staff signatures to confirm they had read the material. There were no return demonstrations or practical evaluations to verify competency in physical skills for any nurse aide. This approach was confirmed to be standard practice for all nurse aides employed by the facility, as discussed with the Nursing Home Administrator and the Director of Nursing.
Failure to Investigate and Address Smoking Hazards
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for two residents, as evidenced by multiple documented incidents involving the presence and use of potentially hazardous and illegal smoking materials. For one resident, nursing documentation twice noted a strong smell of marijuana in the resident's room, with the resident admitting to using marijuana for pain relief. Despite these observations and notifications to supervisory staff, there was no evidence in the clinical record that the facility administration investigated these incidents or took further action to address the presence of illegal substances. Additionally, another resident was found with a vape device and was later caught smoking a cigarette in her room, with a lighter also present. Social services documentation confirmed the resident admitted to receiving a cigarette from another resident. Despite staff awareness and documentation of these events, there was no evidence that the facility conducted an investigation, obtained staff witness statements, or implemented interventions such as room searches to remove hazardous smoking materials. Interviews with facility leadership confirmed their awareness of these incidents and the lack of follow-up investigation or remedial action.
Failure to Implement COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices related to COVID-19, resulting in deficiencies in work exclusions for staff, contact tracing for residents, and the application of transmission-based precautions (TBP). Specifically, two employees who tested positive for COVID-19 returned to work before meeting the facility’s own policy requirements for return-to-work criteria, including the absence of two negative antigen tests. Both employees provided direct care to residents during their infectious periods, and there was no evidence that residents potentially exposed by these staff members were tested for COVID-19 as required by CDC guidance. Additionally, the facility did not conduct contact tracing for residents who were diagnosed with COVID-19, including those who had received aerosol-generating procedures or had close contact with other residents and staff. For example, residents who were hospitalized with COVID-19 or pneumonia did not have their close contacts identified or tested, and there was no documentation of universal source control measures, such as mandatory mask use, being in place during the outbreak. The facility also failed to implement TBP for residents who returned from the hospital with a recent COVID-19 diagnosis or who tested positive while in the facility, with delays or lack of documentation regarding the initiation of appropriate isolation precautions. Interviews with facility leadership confirmed these lapses, including the absence of contact tracing, lack of universal masking, and failure to follow both facility policy and CDC recommendations for testing and isolation. The report also notes that multiple residents and staff across two nursing units tested positive for COVID-19 within a short period, yet the facility did not initiate broad-based testing or enhanced precautions as outlined in national guidance. These actions and inactions directly contributed to the cited deficiencies in infection prevention and control.
Failure to Provide Complete Discharge Summaries
Penalty
Summary
The facility failed to provide a discharge summary with the necessary components for two residents, CR1 and CR2, upon their planned discharge. For Resident CR1, the nursing documentation indicated that the resident was discharged to home with home health services on July 10, 2024. However, the electronic discharge summary did not show evidence that the resident or her responsible party received the document, nor did it include a reconciliation of all medications with the resident. Similarly, for Resident CR2, the nursing documentation noted that arrangements were made for home health and infusion therapy to assist with wound treatment and continuous antibiotic infusion at home. The discharge summary reviewed with Resident CR2 included future appointments but lacked documentation of the disposition or reconciliation of medications. There was no evidence that the resident or her responsible party received the discharge summary, and it did not include a reconciliation of all medications. The facility confirmed during an interview that there was no evidence of discharge instructions, including medication reconciliation, being provided to the residents or their responsible parties.
Inadequate COVID-19 Precaution Signage and PPE Usage
Penalty
Summary
The facility failed to maintain an environment free from the potential spread of infection for two residents who were under COVID-19 transmission-based precautions. The facility's policy on infection prevention and control measures, last reviewed on August 1, 2023, was supposed to follow CDC guidelines to prevent COVID-19 transmission. However, observations revealed that the signage for droplet precautions was inadequate, as it did not include necessary instructions for eye protection and was improperly modified by writing 'Droplet' over 'Contact' on the signs. Resident 1 and Resident 3 were both isolated due to positive COVID-19 tests, with Resident 1's positive status communicated to his nephew on July 31, 2024, and Resident 3 testing positive on July 29, 2024. Observations on August 1, 2024, showed that the signage on their doorways did not meet the requirements for droplet precautions, lacking instructions for eye protection. The PPE organizers at their doors contained gowns, gloves, surgical masks, and N95 masks, but the signage did not specify which type of mask was required. Interviews with staff confirmed the deficiencies in the signage and PPE usage. Employee 3, a registered nurse, acknowledged that the signage did not include necessary droplet precaution measures. Employee 2, a nurse aide, admitted to using a surgical mask instead of an N95 mask while caring for Resident 1, due to unclear instructions on the signage. The surveyor discussed these concerns with the Nursing Home Administrator and a clinical consultant, highlighting the facility's failure to adhere to proper infection control protocols.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food items and maintain equipment in a safe and sanitary manner in the main kitchen. During an initial tour, multiple deficiencies were observed, including dead insects and debris in ceiling light covers, opened bread products without open dates, and a build-up of debris on storage racks and at the kitchen perimeter. The steamer exhaust area had a significant dust build-up, and a container identified as clean had a dead insect inside. Additionally, a coffee container was broken, and plastic cups were stained with debris in their storage container. Unlabeled and undated food items, such as cereals, bread, and brown sugar-like substances, were found, and there was an accumulation of debris on various kitchen surfaces. Further observations revealed issues with the refrigerator and freezer, including unlabeled and undated food items, dislodged lids on fruit containers, and a significant ice build-up in the freezer due to a bowed door. The facility's temperature log indicated refrigerator temperatures above the desired level on several dates, with no documented corrective actions. The loading dock area also had cobwebs, debris, and dust accumulation. These findings were reviewed with the Dietary Manager, Nursing Home Administrator, and Director of Nursing.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the state bed-hold policy to residents or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for six out of seven residents reviewed for hospitalization concerns. For Resident 3, there was no evidence of written notification provided during hospitalizations on April 3, 2024, and May 10, 2024. Similarly, Resident 19 was transferred to the emergency room on April 15, 2024, without written notification to her representative. Resident 34 also did not receive written notification during transfers on April 7, 2024, and April 20, 2024. Resident 60's hospitalization on February 8, 2024, and May 17, 2024, also lacked the required notification. Additionally, the facility could not provide the necessary documentation for Residents 37 and 59 during their respective hospitalizations. The surveyor confirmed these findings during interviews with the Director of Nursing, the Nursing Home Administrator, and other staff members. The deficiency was previously cited on July 21, 2023, indicating a recurring issue with the facility's compliance with the regulation 483.15(d) Notice of Bed Hold Policy Before/Upon Transfer. The lack of documentation and communication regarding the bed-hold policy represents a failure to uphold resident rights as outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.29(f).
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician addressed pharmacy recommendations for four out of five residents reviewed. For Resident 10, the pharmacist made recommendations on two occasions, but there was no documented evidence in the clinical record to indicate what the recommendations were or if they were acted upon. The Director of Nursing (DON) confirmed that the recommendations could not be located. Similarly, for Resident 46, the pharmacist made recommendations on multiple dates, but again, there was no documentation in the clinical record to show what the recommendations were or if they were acted upon, as confirmed by the DON. Resident 25's clinical record also lacked documentation of pharmacy recommendations made on three separate dates, and the Administrator confirmed these findings. For Resident 22, the clinical record indicated that recommendations were made by the consultant pharmacist, but there was no Clinical Pharmacy Report or documentation of the details of the recommendation or any action taken by a physician. Despite a request for additional information during an interview with the Nursing Home Administrator, the DON, and another employee, the facility did not provide further documentation during the onsite survey.
Inaccurate Clinical Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate clinical documentation for two residents, leading to discrepancies in their medical records. For Resident 20, the clinical records inaccurately indicated that the resident was still receiving hospice care, despite being discharged from hospice services on March 17, 2023. This error persisted in multiple physician's progress notes dated from March 21, 2023, to May 16, 2024, which continued to mention hospice care and treatment plans related to hospice, even though the resident was no longer under such care. The Nursing Home Administrator and Director of Nursing confirmed these documentation errors during an interview. For Resident 50, the facility failed to update the medication orders accurately following the resident's hospitalization from April 30, 2024, to May 7, 2024. The resident's gabapentin prescription was discontinued on May 1, 2024, but subsequent clinical documentation erroneously included gabapentin as part of the resident's pain management plan. This error was confirmed by the Director of Nursing, who acknowledged that there was no current order for gabapentin in the electronic medical record, indicating a documentation error.
Deficient Arbitration Agreements Compromise Neutrality
Penalty
Summary
The facility's arbitration agreements were found to be deficient in ensuring a neutral and fair arbitration process for six residents who had signed these agreements. The agreements allowed the facility to select the arbitrator initially or if the parties could not agree on a neutral arbitration service within 30 days. This was evident in the agreements signed by Residents 34, 47, 16, 62, 49, and 26, where the facility retained the power to choose the arbitrator, potentially compromising the neutrality of the arbitration process. Interviews with facility staff, including Employee 13 from medical records, confirmed that the arbitration agreements for the mentioned residents allowed the facility to select the arbitrator. This was further corroborated during a discussion with the Nursing Home Administrator, the Director of Nursing, and a clinical consultant. The deficiency was identified under the Pennsylvania Code sections related to the responsibility of the licensee, management, and resident rights.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions (EBP) for four residents, as required by the CMS memo released on March 20, 2024. The memo mandates the use of EBP, including gown and glove use, for residents with chronic wounds or indwelling medical devices during high-contact care activities. Observations and clinical record reviews revealed that Residents 25 and 49, both with indwelling urinary catheters, did not have documented evidence of EBP implementation, nor was there any signage or PPE present in their rooms to indicate such precautions. Similarly, Resident 59, who had a Stage 4 pressure ulcer, also lacked documentation and visible evidence of EBP in her room. Additionally, Resident 60, who had an indwelling urinary catheter and a pressure ulcer, was observed with her urinary collection bag stored directly on the floor, and the dignity bag meant to hold the collection bag was empty. Although a PPE organizer was present, there were no bins for discarding PPE before leaving the room. Interviews with staff, including a nurse aide and a licensed practical nurse, confirmed the lack of communication and implementation of EBP for these residents. The Director of Nursing and the Administrator acknowledged these deficiencies during the surveyor's review.
Lack of Qualified Infection Preventionist in Facility
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. The previous Director of Nursing, who held the position of Infection Preventionist, left the facility on June 2, 2024. Following her departure, a licensed practical nurse assumed the role without having completed any specialized training in infection prevention and control. Interviews with the Nursing Home Administrator confirmed that no current staff members had the necessary qualifications or training for the role. Additionally, the facility was unable to provide evidence of infection control committee meetings since the last standard survey in July 2023. The Director of Nursing admitted to attempting to monitor antibiotic use and infection prevalence but could not provide a current line listing of infections or evidence of antibiotic surveillance. Furthermore, she did not have access to the Pennsylvania Patient Safety Reporting System and was unaware of who was responsible for this task. These findings were confirmed in a joint interview with the Director of Nursing, the Nursing Home Administrator, and a clinical consultant.
Failure to Offer COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to four out of five residents reviewed for immunization concerns, as per the guidelines set by the Centers for Disease Control (CDC). The facility's policy on COVID-19 infection prevention and control measures, last reviewed on August 1, 2023, did not include provisions for educating residents about the benefits and risks of the COVID-19 vaccine, nor did it document the education provided or the administration of vaccines. Clinical record reviews revealed that Residents 2, 35, 36, and 60 had not been offered the updated 2023-2024 COVID-19 vaccines, despite their last immunizations being dated back to 2021 or 2022. Interviews with the Director of Nursing, the Nursing Home Administrator, and a clinical consultant confirmed that there was no additional evidence to show that these residents were provided with education or the opportunity to receive the updated COVID-19 vaccines. This lack of action was in violation of the facility's own policies and the CDC's recommendations, as well as state regulations regarding medical records and resident care policies.
Failure in Pressure Ulcer Care and Infection Prevention
Penalty
Summary
The facility failed to provide adequate treatment and services to promote healing and prevent infections for pressure ulcers in two residents. Resident 58 had a physician's order for wound care on her coccyx, which was not consistently followed by the nursing staff. The Treatment Administration Record (TAR) showed missed treatments on several occasions in March 2024, and there was no documented evidence of wound assessment or measurement until a wound consultant evaluated it in late April 2024. The wound was assessed as a Stage 4 pressure ulcer, indicating severe tissue loss. Additionally, there was no documentation of assessments for several weeks in April 2024. Resident 59 also experienced lapses in wound care as per physician's orders. The TAR indicated missed treatments in March, April, and May 2024. An observation in June 2024 revealed improper wound care technique by an LPN, who failed to change gloves and wash hands between handling supplies and applying a clean dressing. This was confirmed by an interview with the Director of Nursing, highlighting the facility's failure to adhere to proper wound care protocols.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered nutritional interventions for two residents identified as being at nutritional risk. Resident 25's care plan indicated the need for a nutritional supplement, Boost, to maintain skin integrity. Despite a physician's order to provide 8 oz of Boost twice daily, the Medication Administration Record (MAR) for April and May 2024 showed multiple instances where the supplement was not administered due to it being unavailable or on order. This lack of administration coincided with the development of a small open area on Resident 25's scrotum, as noted in nursing documentation. Similarly, Resident 59, who had an open wound, was ordered to receive Boost twice daily before meals. However, the MAR for April and May 2024 documented numerous occasions where the supplement was not given due to unavailability. This resident experienced a significant weight loss of 9 percent in one month, as noted in a dietary report. Interviews with facility staff confirmed that the supply of Boost was not consistently received as ordered, acknowledging the deficiency in providing necessary nutritional support.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment in the Ivy Nursing Unit and a dining room, as observed during a survey. In the dining room adjacent to the main kitchen, surveyors noted various stains on the floor, debris in the protective covers of overhead lights, stained and cracked ceiling tiles, dust and debris on windowsills, and dried splash stains on the windows. These observations were made on two consecutive days, indicating a lack of adequate housekeeping and maintenance services. In the shower room, surveyors observed a scratched and stained commode seat, chipped paint, dead insects in the ceiling light cover, debris under the shower gurney cushion, cobwebs in an opening in the brick wall, discarded linens on the sink, and debris in the shower drain. These conditions were consistent over two days, with additional linens found on the second day. The findings were discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide a homelike environment as required by regulations.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to complete a restorative nursing program for a resident with osteoarthritis, abnormalities of gait and mobility, and muscle weakness. The resident's care plan required assistance with walking and transferring, with a goal to ambulate up to 70 feet with a rolling walker and one-assist daily. The physical therapy discharge summary recommended a restorative nursing program with a good prognosis, contingent on consistent staff follow-through. However, documentation revealed that the restorative task was not completed on several occasions, with specific dates in May and June marked as not applicable. Interviews with facility staff revealed a lack of clarity and follow-through regarding the restorative program. The Director of Therapy was unsure about the meaning of 'Not Applicable' in the documentation, while a nurse aide indicated that she marked 'Not Applicable' when she did not observe the resident completing the program during her shift. This lack of consistent implementation and documentation of the restorative nursing program led to the deficiency, as the facility did not adhere to the recommended therapy discharge plan for the resident.
Deficiency in PICC Line and Pacemaker Care
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with a PICC line and an implanted pacemaker. The surveyor found that the facility did not have a policy or procedure for PICC line care, and there was no signage or information to prevent the use of the resident's right arm for blood pressure readings or venipunctures. Additionally, there were no emergency supplies available in the resident's room in case of complications with the PICC line. The clinical record review revealed that there was no care plan developed for the resident's bacteremia diagnosis, intravenous antibiotic administration, PICC line use, or pacemaker care. The resident was admitted with a diagnosis of bacteremia and required intravenous antibiotics for six weeks. The resident also had a surgical history of pacemaker implantation. Observations showed that the PICC line site was clean and dry, but there were no precautions in place to protect the arm with the PICC line. Interviews with staff confirmed the lack of signage and emergency supplies. The facility did not have a care plan addressing the resident's medical needs, and the necessary equipment for pacemaker monitoring was not initially available in the resident's room.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 66 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Athens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Waverly | 3.1 mi | ★★★★★ | 2 | 1 |
| Sayre Health Care Center | 3.1 mi | ★★★★★ | 19 | 0 |
| Robert Packer Hospital Skilled Care And Rehabilit | 13.2 mi | ★★★★★ | 15 | 0 |
| Chemung County Health Center - Nursing Facility | 16.5 mi | ★★★★★ | 0 | 0 |
| St. Joseph's Hospital - Skilled Nursing Facility | 16.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.