Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garvey Manor during CMS and state inspections, most recent first.
A resident with dementia, anxiety, and depression was restarted on risperidone for agitation/verbal aggression after a failed GDR, but the record did not show that the resident representative was informed in advance of the medication’s risks, benefits, and treatment alternatives. The DON confirmed there was no documented informed consent before the antipsychotic was initiated, and that families had previously been notified of order changes without discussion of risks, benefits, or alternative interventions.
Call Bell Not Within Reach: A resident with dementia, orthostatic hypotension, and a recent fall had a care plan directing staff to keep the call bell within reach, but it was observed on the bed and not accessible while she was sitting in a recliner. The resident said she takes herself to the bathroom, and an LPN confirmed she was supposed to use the call bell for assistance and that it should have been within reach; the DON also confirmed this. A motion alarm was in place near the bathroom area, and the resident had a bruise on her face from a fall.
A resident with cognitive impairment and BPH had urinary complaints, flank pain, increased confusion, and low temperatures documented in the chart. The record did not show that the attending physician or legal representative was promptly notified of the change in condition, and the DON confirmed the notifications were not made promptly.
A resident with cognitive intactness, dependence for daily care, incontinence, cancer, morbid obesity, hemiplegia/hemiparesis, diabetes, and pressure ulcers was found yelling out and showing a painful bruise on the L hand, but could not explain how it happened. The bruise was reported to the team lead, yet there was no documented abuse investigation and no documented evidence that the physician or resident representative were notified; the DON confirmed no investigation was completed.
Care plans were not updated to reflect the current needs of two residents. One resident with ESRD on HD had a care plan that still referenced a fistula even though observation showed a hemodialysis catheter and no fistula, and the NHA confirmed the discrepancy. Another resident’s care plan listed bilateral nephrostomy tubes and CPAP use, but the clinical record had no evidence or orders for either device; the DON confirmed the care plan should have been revised.
Failure to follow care orders and timely psych med recommendations: A resident with severe cognitive impairment was found without ordered leg protectors despite a care plan and MD orders for skin protection. Another resident with dementia, anxiety, and depression had a failed GDR of Risperdal with increased agitation and verbal aggression, but the psychiatry recommendation to restart risperidone was not addressed promptly; the MD was contacted days later and the order was not obtained until several days after the recommendation.
Failure to notify physician and document pressure ulcer care: A resident with significant comorbidities, including diabetes, morbid obesity, and hemiplegia, developed an open sacral area that later progressed to a coccyx/right buttock pressure ulcer. The RN documented the initial skin opening and a later skin assessment noted questionable MASD, but there was no documented physician notification, no documented weekly assessment, and no documented evidence of preventive measures or barrier cream application. Ordered wound treatments were also not documented as completed on multiple occasions in the TAR, despite the DON stating staff had performed them but failed to sign.
Incomplete neurological checks were documented for a resident who fell in the bathroom and sustained a head injury, with monitoring stopped before the full policy-required period was completed after hospital evaluation. The facility also failed to complete quarterly elopement risk assessments for a cognitively impaired resident with Alzheimer's disease and a history of wandering and exit-seeking behaviors.
Staff failed to provide proper catheter care for two residents with indwelling urinary catheters. One resident with a suprapubic catheter and another resident with urinary retention were observed with drainage bags touching the floor, and one bag was not covered with a dignity bag. An aide and the DON confirmed the bags should have been kept off the floor and, for one resident, covered with a dignity bag.
The facility failed to maintain accountability for a resident’s controlled pain medication. A cognitively intact resident with metastatic cancer received fentanyl patches for pain, but the MAR and controlled drug count record did not show that the old patches were destroyed and witnessed by two licensed nurses as required by policy.
An insulin pen for a resident with diabetes was found open and in use in a medication cart without a date. Facility policy required multi-dose injectables to be dated when opened, and both an LPN and the DON confirmed the pen should have been dated.
Food storage was not maintained in sanitary conditions. Surveyors observed a metal cart in the walk-in cooler with two trays of red velvet cake left uncovered and exposed to air, along with packaged sliced red onions past the manufacturer used-by date. The Dietary Mgr and Dietary Dir confirmed the rack cover should have been in place and the onions should have been discarded.
Staff failed to follow EBP for two residents with extensive care needs. One resident had cellulitis and leg wounds, and during wound care the RN/Skin Care Coordinator and a nurse aide wore gloves only instead of gown and gloves. Another resident had a GT for nutrition, and during GT flushing an LPN wore gloves only and did not sanitize hands after glove removal. The Infection Control Nurse and ADON confirmed the residents were on EBP and that proper PPE and hand hygiene were required.
A resident who was cognitively intact and able to communicate reported that eggs served for breakfast were unpalatable, and direct observation confirmed that several food items, including eggs, French toast, and milk, were served at temperatures below facility standards. Staff acknowledged the difficulty in maintaining proper temperatures during tray delivery, resulting in food that was not appetizing or safe.
A dietary aide was observed working in the kitchen with uncovered facial hair, contrary to facility policy requiring hair and beard restraints. The Dietary Director confirmed that the staff member should have been wearing a beard restraint.
The facility did not ensure a clean, homelike environment on the D1 wing, as repeated observations found large brown and black stains on the hallway and lounge carpeting. Staff confirmed that housekeeping was unable to remove the stains and that the carpet needed replacement.
A resident with dementia and other serious conditions, who required total assistance and was known to be resistive to care, was subjected to verbal abuse by a physical therapist during a therapy session. The therapist became impatient, raised her voice, and made derogatory remarks about the resident in the presence of other staff, despite the resident's refusal to participate. Multiple staff witnessed the incident, which was found to be a violation of abuse prevention policies.
The facility did not complete required license checks before hiring two RNs, as personnel files showed both began work before their licenses were verified. Staff interviews confirmed that license verifications were not done prior to employment, in violation of facility policy on background checks and screening.
A resident with a hip fracture and requiring maximum assistance was found on the floor after the required motion sensor alarm was not present or activated as specified in the care plan. Facility policy required the alarm for safety, but staff failed to ensure it was in place, as confirmed by the DON.
The facility did not obtain Pennsylvania Nurse Aide Registry checks before two nurse aides began employment, as required by policy and state regulations. Personnel files and staff interviews confirmed that the registry checks were completed after the aides had already started working.
The facility failed to assess a resident for safety in a chair after a history of falls, leading to a fracture, and did not follow fall prevention protocols for another resident with a history of falls. Despite incidents, there was no documented evidence of safety assessments or adherence to care plans requiring hourly safety checks.
A resident's needs were not reasonably accommodated as her call bell was not within reach, despite her care plan requiring it. She was observed attempting to ambulate without supervision, and her call bell was found on the floor behind her nightstand. Staff interviews confirmed the call bell should have been accessible.
The facility failed to accurately complete MDS assessments for two residents, omitting the indication of oxygen therapy use as required by the RAI User's Manual. Despite physician orders for oxygen therapy due to respiratory conditions, the assessments did not reflect this, as confirmed by the LPN responsible for the documentation.
The facility failed to develop individualized care plans for two residents, one with diabetes mellitus and another requiring comfort care. A resident receiving insulin had no care plan for diabetes management, while another's care plan lacked comfort care measures despite physician orders. These deficiencies were confirmed by the DON.
The facility failed to update care plans for two residents to reflect discontinued medications, as confirmed by the DON. One resident's care plan still included Keppra despite a physician's order to discontinue it, and another's included Eliquis, which was also discontinued. The facility policy requires care plans to be revised with changes in condition, which was not followed.
The facility failed to obtain physician orders for pacemaker checks for two residents and did not ensure a registered nurse assessed a resident after an elopement incident. Both residents with pacemakers lacked documented orders, and a resident who eloped was not assessed upon return, as confirmed by the DON.
A resident with Parkinson's disease experienced an unwitnessed fall, and the facility failed to complete the required neurological checks as per their policy. The checks were initiated but not fully documented, as confirmed by the DON.
A resident at risk for pressure injuries did not have a physician-ordered left elbow splint in place, despite it being necessary for skin integrity. The resident, with cognitive impairment and medical conditions like stroke, was observed without the splint, which was found in the room. Interviews confirmed the splint's importance and lack of documented refusal by the resident.
A facility failed to follow physician's orders for tracheostomy care for a resident with chronic respiratory failure. Despite orders for daily care and sponge application, records showed no evidence of care on specific days, confirmed by the ADON. This constituted a deficiency in nursing services.
The facility did not complete annual performance evaluations for two nurse aides, despite being hired over a year ago. This was confirmed through personnel file reviews and an interview with the DON, who could not provide documentation of the evaluations.
The facility's QAPI committee failed to address recurring deficiencies effectively, resulting in repeated issues with assessment coding, care plan development and revision, professional standards, and quality of care. Despite having plans of correction, the facility was unable to maintain compliance, as evidenced by repeated citations in consecutive surveys.
Failure to Obtain and Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications and the treatment alternatives prior to initiating risperidone for one resident. Facility policy dated June 20, 2025 stated that when a psychotropic medication is initiated or increased, the resident and/or representative must be informed of the rationale, benefits, risks, and alternatives, and that consent and education must be documented in the medical record before the medication is started using the psychotropic UDA. Resident 47 had a quarterly MDS dated March 11, 2026 showing cognitive impairment, dependence on staff for daily care needs, and use of psychotropic medications including antipsychotic, antianxiety, and antidepressant medications, with diagnoses of dementia, anxiety, and depression. A psychiatry note documented a failed GDR of risperidone due to increased verbal aggression and a rebound of verbal aggression after discontinuation, with the POA reporting anger toward him. Risperidone 0.5 mg at bedtime was reordered for verbal aggression/agitation, but there was no documented evidence that the resident representative was informed in advance of the risks, benefits, and treatment alternatives before the medication was restarted. The DON confirmed there was no such documentation and stated that prior to May 18, 2026, families were notified of order changes but not of risks, benefits, or alternative interventions.
Call Bell Not Within Reach
Penalty
Summary
The facility failed to ensure that the call bell was within reach for one resident who had dementia, orthostatic hypotension, a recent fall without injury, and required moderate assistance with transfers and ambulation. The resident’s care plan included keeping the call bell within reach and in view when in the room, and the facility policy stated that call bells are to be kept within reach unless otherwise indicated in the plan of care. During observation, the resident was sitting in a recliner to the left of her bed, with a motion alarm in place near the bathroom door frame and a bruise on the left side of her face that she said was from a fall. Her rollator walker was within reach, and she stated that she takes herself to the bathroom if needed. When asked to use the call bell, the resident picked up her phone from the overbed table, but the call bell was observed on the bed near the upper right side and not within her reach. An LPN confirmed that the resident was supposed to ring for assistance and that the call bell was not in reach and should have been. The DON also confirmed that the call bell should have been within reach, while noting that the resident sometimes gets in and out of bed herself. During the observation, standing at the foot of the bed set off the motion alarm, and the alarm also sounded when the resident’s room was observed, indicating movement past the end of the bed toward the recliner.
Failure to Promptly Notify Physician and Legal Representative of Change in Condition
Penalty
Summary
The facility failed to ensure that the attending physician and legal representative were promptly notified of a change in condition for Resident 53. The resident’s record showed cognitive impairment, dependence on staff for daily care needs, and a diagnosis of benign prostatic hyperplasia. The care plan identified a potential for complications with urinary elimination and directed staff to observe and document signs and symptoms of infection, including frequency, burning, pain, or discomfort. Nursing documentation showed that Resident 53 complained of burning upon voiding and flank pain, later continued to complain of burning with urination, and was noted to have increased confusion and low temperatures, including a recorded temperature of 95.9 degrees Fahrenheit. A physician communication report later documented increased confusion since May 15, 2026, subtherapeutic temperatures as low as 91 and 95 degrees Fahrenheit, and complaints of dysuria and flank pain. There was no documented evidence that the attending physician and legal representative were promptly notified of these changes, and the DON confirmed in interview that they were not notified promptly and should have been.
Failure to Investigate Unexplained Bruise
Penalty
Summary
The facility failed to conduct a thorough investigation to rule out abuse or neglect for a resident who was found with a bruise on the left hand. The resident was cognitively intact, usually able to be understood and to understand others, dependent on staff for daily care needs, incontinent of bowel and bladder, and had diagnoses including cancer, morbid obesity, hemiplegia and hemiparesis following cerebral infarction, and diabetes. The resident also had two unstageable pressure ulcers not present on admission. A social services note documented that the resident was yelling out "Help me" and "ouch," and showed the social worker a painful bruise on the left hand, but could not recall how it occurred. The team lead was notified, but there was no documented evidence that the bruise was investigated to rule out abuse and no documented evidence that the physician or resident representative were informed. The Social Services Director confirmed she reported the bruise to the team lead but could not recall who it was, and the DON confirmed she was not made aware of the bruise and that no investigation had been completed.
Care plans not revised to match residents’ current care needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect residents’ specific care needs for 2 of 43 residents reviewed. Facility policy stated that resident care plans are to be reviewed or modified at least quarterly, upon a significant change in condition, or according to the target date on the care plan. For one resident, an admission MDS dated April 13, 2026, showed the resident was cognitively intact, wore hearing aids, understood and could understand others, required assistance with care needs, had end stage renal disease, and received dialysis on Tuesday, Thursday, and Saturday through a hemodialysis catheter. However, observation and interview on June 3, 2026, showed the resident had a hemodialysis catheter in the right upper chest and no fistula in the right upper arm, while the care plan dated April 6, 2026, directed staff to observe the resident’s fistula every shift and upon return from dialysis. The NHA stated the care plan should have been revised to reflect that the resident did not have a fistula in the right arm. For another resident, a significant change MDS dated January 15, 2026, showed the resident was cognitively intact, needed assistance with daily care needs, and had diagnoses including anxiety and bipolar disorder. A quarterly MDS dated May 4, 2026, showed the resident was cognitively intact, usually able to be understood and to understand others, dependent on staff for daily care needs, incontinent of bowel and bladder, receiving hospice care, and diagnosed with chronic kidney disease stage 3 and obstructive sleep apnea. The resident’s care plan dated August 14, 2023, stated the resident had bilateral nephrostomy tubes, but the clinical record contained no documented evidence of nephrostomy tubes or physician orders for them. Another care plan dated August 28, 2023, stated the resident had sleep apnea and used a CPAP machine, but the clinical record contained no documented evidence of a CPAP machine or physician orders for one. The DON confirmed the care plan should have been revised to reflect that the resident did not have nephrostomy tubes or a CPAP machine.
Failure to Follow Care Orders and Timely Psychiatric Medication Recommendations
Penalty
Summary
The facility failed to follow physician orders for a resident who was severely cognitively impaired and had a care plan directing that she always wear leg protectors except during hygiene care to help prevent skin breakdown related to impaired skin integrity. Her record also included orders for protocols to prevent skin breakdown, total body skin checks twice a week, and a specialized pressure-reducing mattress. During an observation, she was found lying in bed without her leg protectors on. A nurse aide later checked the room for the protectors and could not find them, and the Nursing Home Administrator confirmed that the resident should have had her bilateral leg protectors on as ordered and care planned. The facility also failed to ensure that psychiatric medication recommendations were completed timely for a resident with dementia, anxiety, and depression who was dependent on staff for daily care and had instances of rejection of care. The resident had been receiving psychotropic medications, including antipsychotic, antianxiety, and antidepressant medications. After the resident’s son reported increased anger, agitation, anxiety, confusion, aggression, decreased appetite, weight loss, tearfulness, and depression following discontinuation of Risperdal, psychiatry documented that the resident had a failed gradual dose reduction of risperidone due to increased verbal aggression and rebound aggression after discontinuation. Psychiatry recommended restarting risperidone 0.5 mg at bedtime, and the son agreed with the recommendation. The recommendation was faxed to the physician, but the clinical record showed the physician was not contacted until three days after the recommendation, a second attempt was made five days later, and the medication was not ordered until eight days after the initial recommendation. During that period, medication administration notes documented the resident as resistive to care and verbally aggressive with staff. The DON confirmed that the psychiatry recommendation should have been addressed sooner.
Failure to Notify Physician and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to notify the physician of a wound that progressed to a pressure ulcer, failed to ensure treatments were in place to prevent progression of pressure ulcers, and failed to ensure that pressure ulcer treatments were completed as ordered for one resident. The resident was cognitively intact, dependent on staff for daily care needs, incontinent of bowel and bladder, and had diagnoses including cancer, morbid obesity, hemiplegia and hemiparesis following cerebral infarction, and diabetes. The resident's quarterly MDS identified two unstageable pressure ulcers that were not present on admission. A nursing note documented an open area on the resident's mid lower sacral area during incontinent care, and the RN noted a superficial open area measuring 0.4 cm by 0.3 cm by 0.1 cm. The RN instructed the nurse aide to apply barrier cream, and a skin observation tool was completed and sent to the skin care coordinator RN. A later skin assessment tool described the area as questionable MASD, but there was no documented evidence that the physician was notified, that the skin care coordinator assessed and identified the wound, that preventative measures were in place to prevent pressure ulcers, that barrier cream was applied, or that the wound was assessed weekly. The wound later progressed to a coccyx/right buttock pressure ulcer, and physician orders were written for daily wound care with normal saline cleansing, calcium alginate AG, and dressings such as ABD pads or Allevyn, later changed to Dakins with continued dressing care. The TAR showed no documented evidence that ordered treatments were completed on multiple dates in April and May 2026. The DON stated that staff did perform the treatments on those dates but forgot to sign the treatment record, and confirmed there was no documented evidence that the treatments were completed as ordered.
Incomplete Neurological Monitoring and Elopement Risk Assessments
Penalty
Summary
Neurological checks were not completed per facility policy for a resident who sustained a head injury after a fall. Resident 24 had cognitive impairment, required moderate assistance with transfers, supervision with walking, used a wheelchair, and had a history of falls and a recent fracture. After falling in the bathroom and being found lying face down with blood on the floor, a nosebleed, a laceration above the right eyebrow, and a skin tear below the right eye, the resident was assessed by the RN, found to have neurological checks within normal limits, and sent to the hospital for evaluation. When the resident returned from the hospital, neurological checks were resumed and documented for several intervals, but the record showed they were stopped before the full 24-hour monitoring period required by policy, and there was no documented evidence that the checks were restarted to complete the required monitoring. The facility also failed to complete elopement risk assessments quarterly for a resident with known wandering and exit-seeking behaviors. Resident 115 was cognitively impaired, dependent on staff for daily care needs, and had a diagnosis of Alzheimer's disease. The resident had an elopement risk assessment completed on admission, and an elopement risk care plan was initiated because of wandering and exit-seeking behaviors. Quarterly elopement risk assessments were documented in 2023 and 2024, and one assessment was completed in March 2025, but there was no documented evidence that quarterly assessments were completed for the remainder of 2025 as required by facility policy.
Improper urinary catheter bag placement and missing dignity bag
Penalty
Summary
The facility failed to ensure proper care for indwelling urinary catheters for two residents. The facility policy dated June 20, 2025 stated that urinary catheter care was intended to ensure safe handling of the catheter to reduce the risk of urinary tract infections, including keeping the catheter bag in a catheter bag cover/dignity bag and keeping the dignity bag and tubing off the floor. Resident 47 had a suprapubic catheter, was cognitively impaired, dependent on staff for daily care, and had diagnoses including neurogenic bladder. During an observation, Resident 47 was in a low bed with the catheter drainage bag and tubing lying in direct contact with the floor, and a gray basin was under the bed. A nurse aide confirmed the bag and tubing were on the floor and stated the bag was typically placed in a basin so it would not touch the floor; the DON also confirmed the bag and tubing should have been off the floor and in a gray basin. Resident 92 had an indwelling urinary catheter and diagnoses including chronic kidney disease with urinary retention. Physician orders directed staff to ensure the urine collection bag was positioned off the floor and covered with a dignity bag for dignity and infection prevention. During an observation, Resident 92 was lying on a low bed with the catheter drainage bag touching the floor on the right side of the bed, and there was no catheter bag or dignity bag on the drainage bag. A nurse aide confirmed the bag should have had a dignity bag and should not have been touching the floor, and the DON also confirmed that the drainage bag should have had a dignity bag and should not have been touching the floor.
Controlled Medication Destruction Not Documented
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident who was cognitively intact, had a diagnosis of metastatic cancer, and received routine and as-needed pain medication, including opioid therapy. Physician orders included fentanyl transdermal patches, 50 mcg every 72 hours for pain related to metastatic cancer. Review of the Medication Administration Record and controlled drug count record showed fentanyl patches were applied on multiple occasions in February, April, and May 2026. The facility policy for controlled substances stated that when a controlled substance is removed for administration and must be destroyed, the destruction and documentation must be witnessed by two licensed nurses. For the resident’s fentanyl patches, there was no documented evidence that two staff members witnessed and signed for destruction of the old patch after removal on the identified dates. The Director of Nursing confirmed that the documentation showing two staff witnesses for destruction of the removed patches was not present.
Undated Insulin Pen in Medication Cart
Penalty
Summary
The facility failed to date an insulin pen in one of three medication carts reviewed, specifically the C1 medication cart. Facility policy required multi-dose injectables to be discarded according to the manufacturer’s recommendations or one year from the date opened, whichever was less, and stated that if a specific expiration date was indicated, a sticker with the date opened and date expired would be attached and completed by nursing or pharmacy. Resident 17 had an order for Novolog Mix 70/30, 24 units subcutaneously with meals for diabetes mellitus. During observation of the C1 medication cart, surveyors found a Novolog 70/30 multi-dose injectable pen for Resident 17 that was open but not dated and was in use. An LPN confirmed at the time of observation that the pen should have been dated when opened and was not, and the DON later confirmed that insulin pens should be dated when opened and in use.
Food Storage Not Maintained in Sanitary Conditions
Penalty
Summary
Food was not stored under sanitary conditions in the dietary area. Facility policy dated June 20, 2025 stated that food storage areas shall be maintained in a clean, safe, and sanitary manner. During an observation in the walk-in cooler on June 1, 2026, at 9:23 a.m., surveyors found a metal cart with two trays of red velvet cake with white icing that were not covered and were exposed to air, and the cart was uncovered on one side. In the same area, there was a box of packaged sliced red onions with a manufacturer used-by date of May 28, 2026. The Dietary Manager confirmed the observation at 9:25 a.m., and the Dietary Director stated that the rack cover should have been in place and the sliced onions should have been discarded; the onions were special food for Memorial Day.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow infection control guidelines from CMS and CDC for two residents who were on Enhanced Barrier Precautions. Resident 1 was cognitively intact, required extensive assistance with care needs, and had left lower cellulitis with leg wounds. Physician orders directed daily wound care, and the care plan identified actual impaired skin integrity and EBP with gown and glove use for all direct contact. During observed wound care, the RN/Skin Care Coordinator and a nurse aide performed the care wearing gloves only and did not use the proper PPE. Resident 4 was severely cognitively impaired, had unclear speech that was usually understood, required extensive assistance with care needs, had a stroke diagnosis, and had a gastrostomy tube for nutrition. The resident’s care plan identified EBP with gown and glove use for all direct contact. During observed GT water flushing, an LPN wore gloves only instead of the required PPE and did not hand sanitize after glove removal. The LPN confirmed the resident was on EBP and that proper PPE and hand hygiene should have been used. The Infection Control Nurse and Assistant DON also confirmed that both residents were on EBP and that staff should have worn appropriate PPE and performed hand hygiene after glove removal.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing and safe temperatures, as required by their policy and regulatory standards. According to the facility's policy, food temperatures are to be checked prior to service, with hot foods reheated if they fall below 165°F. During a breakfast meal service observation, it was noted that food trays were delivered to residents' rooms over a span of more than 20 minutes. Temperature checks of a test tray revealed that several items, including scrambled eggs, French toast, fried eggs, and milk, were not at palatable or safe temperatures. Specifically, scrambled eggs were 121.7°F, French toast was 112.6°F, fried eggs were 108°F, and milk was 56.1°F, all below the expected standards for serving. A resident who was cognitively intact and able to communicate clearly reported that the eggs tasted like plastic, indicating dissatisfaction with the food quality. Staff interviews confirmed that maintaining proper temperatures for certain items, especially eggs, during room delivery was challenging. The Dietary Supervisor and Dietary Director acknowledged that the milk, French toast, and fried eggs should have been served at palatable temperatures, but this was not achieved during the observed meal service.
Failure to Ensure Proper Use of Hair Restraints in Kitchen
Penalty
Summary
The facility failed to comply with professional standards for food service safety by not ensuring that all dietary staff wore appropriate hair restraints while working in the kitchen. Specifically, during an observation in the kitchen, a dietary aide was seen working with uncovered facial hair, which was in direct violation of the facility's dietary operations policy requiring hair and beard restraints. This observation was confirmed by the Dietary Director, who acknowledged that the staff member should have been wearing a beard restraint as per policy.
Failure to Maintain Clean and Homelike Environment Due to Stained Carpeting
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the D1 wing. Multiple observations over several days revealed that the carpeting in the D1 hallway and lounge had large brown and black stains. Staff interviews confirmed that, despite housekeeping efforts, the carpet remained stained in multiple areas and required replacement.
Resident Subjected to Verbal Abuse by Physical Therapist During Therapy Session
Penalty
Summary
The facility failed to protect a resident from verbal abuse during a therapy session. The resident, who had dementia, encephalopathy, sepsis, and required total assistance for daily care, was known to exhibit physical and verbal aggression and was resistive to care. Her care plan required staff to explain procedures, use diversional conversation, and stop care if the resident became combative, with a re-approach after a cooling-off period. During a therapy session, the physical therapist became impatient and verbally abusive when the resident resisted participation, raising her voice and making derogatory remarks about the resident to another staff member. Multiple staff members witnessed the therapist's escalating tone and frustration during the incident. The physical therapist insisted that the resident participate in therapy, citing insurance requirements, despite the resident's refusal and distress. The therapist's actions included increasing her volume, insisting the resident stand, and making inappropriate comments about the resident's behavior and her own frustration. The incident was reported by other therapy staff who were present and overheard the interaction, confirming the abusive behavior. The facility's failure to ensure the resident was free from abuse constituted a deficiency in compliance with abuse prevention policies.
Failure to Complete License Checks Prior to RN Hire
Penalty
Summary
The facility failed to ensure that license checks were obtained prior to hire for two Registered Nurses. Review of personnel files showed that both nurses began employment before their licenses were verified, with one starting work on June 9, 2025, and the license check completed on July 23, 2025, and the other starting on May 27, 2025, with the license check completed on June 6, 2025. There was no documented evidence that license checks were conducted before either nurse's start date. Staff interviews confirmed that the required license verifications were not completed prior to employment, contrary to the facility's policy on preventing abuse, neglect, or mistreatment, which includes protocols for employment background checks and screening.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement an individualized care plan for fall prevention for one resident. According to facility policy, safety alarms are to be used for residents with a history of unassisted transfers when staff assistance is necessary for safety. The resident in question was alert and oriented, required maximum assistance for daily care, had a diagnosis of hip fracture, and was assessed to require a motion sensor alarm at the foot of the bed at all times when in bed. However, a nursing note documented that the resident was found on the floor, and a witness statement confirmed that the alarm was not present at the time of the incident. The Director of Nursing verified that the alarm was not in place and activated as required by the care plan.
Failure to Complete Nurse Aide Registry Checks Prior to Hire
Penalty
Summary
The facility failed to ensure that Pennsylvania Nurse Aide Registry checks were obtained prior to the hire of two nurse aides. Review of personnel files showed that one nurse aide began employment on May 27, 2025, but the registry check was not completed until June 10, 2025. Another nurse aide started on April 7, 2025, with the registry check not performed until July 23, 2025. There was no documented evidence that the required registry checks were conducted before these staff members began working. Staff interviews confirmed that the registry checks should have been completed prior to the start dates, but this was not done, which was not in accordance with the facility's policy and state regulations.
Failure to Conduct Safety Assessments and Follow Fall Prevention Protocols
Penalty
Summary
The facility failed to assess a resident for safety in a chair after a known history of falls, resulting in a fall with a fracture. Resident 2, who required extensive assistance for ambulation and transfers, was found on multiple occasions on the floor near her recliner. Despite these incidents, there was no documented evidence of a safety assessment for the use of her recliner. The resident suffered a fracture to her right shoulder after a fall on January 14, 2024, and was later provided with a motion alarm for her recliner. Additionally, the facility did not follow fall prevention interventions for Resident 5, who had a history of falls and was cognitively impaired. The resident's care plan required hourly safety checks, but there was no documented evidence that these checks were conducted. The resident experienced falls on May 13, 2024, and June 17, 2024, with the latter incident involving a fall from a recliner footrest, resulting in a bump to the head. Interviews with facility staff, including the Director of Nursing, confirmed the lack of documented safety assessments and adherence to fall prevention protocols. The facility's policy required assessments by a registered nurse supervisor if a fall was involved, but this was not consistently followed for the residents in question.
Failure to Ensure Call Bell Accessibility for a Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of Resident 57 by not ensuring that her call bell was within reach. According to the quarterly Minimum Data Set (MDS) assessment dated April 30, 2024, Resident 57 was able to understand and be understood by others and required minimal assistance from staff for care. Her care plan, dated January 9, 2024, specified that staff should encourage her to use her call bell for assistance and ensure it was within reach when she was in her room. A therapy note from July 28, 2024, indicated that she required supervision with ambulation and transfers. However, on July 29, 2024, at 11:03 a.m., an observation revealed that Resident 57 was sitting on her bed attempting to ambulate, and her call bell was found behind her nightstand on the floor, out of reach. Interviews with Nurse Aide 1 and the Director of Nursing confirmed that the call bell should have been accessible to Resident 57.
Inaccurate MDS Assessments for Oxygen Therapy
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) User's Manual. The manual specifies that Section O0100C should be completed to indicate the use of oxygen therapy. For Resident 45, who had a history of aspiration and sleep apnea, the care plan included an order for oxygen therapy. However, the quarterly MDS assessment did not reflect this, as column (2) of Section O0100C was not marked to indicate the use of oxygen. Similarly, Resident 89, who had a history of congestive obstructive pulmonary disease, also had a physician's order for oxygen therapy. Yet, the MDS assessment for this resident also failed to indicate the use of oxygen in the same section. An interview with the LPN responsible for completing the MDS assessments confirmed the inaccuracies in the documentation for both residents, acknowledging that the assessments should have indicated the residents' use of oxygen therapy.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 69, who was cognitively intact and dependent on staff for care, had a diagnosis of diabetes mellitus and was receiving daily insulin injections. However, there was no documented evidence of a care plan for managing the resident's diabetes, which was confirmed by the Director of Nursing during an interview. Similarly, Resident 88, who was also cognitively intact and required extensive assistance for daily care, had a diagnosis of cerebrovascular disease and was under physician orders to receive comfort care. Despite this, the resident's care plan did not include the necessary comfort care measures as ordered by the physician. This oversight was also confirmed by the Director of Nursing, indicating a failure to update the care plan to reflect the resident's current needs.
Failure to Update Care Plans for Medication Changes
Penalty
Summary
The facility failed to update and revise care plans for two residents, which led to deficiencies in reflecting the residents' current care needs. For one resident, the care plan was not updated to reflect the discontinuation of Keppra oral solution, a medication used to control seizures, despite a physician's order to discontinue it. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have been revised to reflect the change in medication. Similarly, another resident's care plan was not updated to reflect the discontinuation of Eliquis, an anticoagulant, as per the physician's order. The care plan still included the anticoagulant, which was no longer prescribed. This was also confirmed by the Director of Nursing during an interview. The facility's policy requires care plans to be evaluated and revised every 90 days, annually, and when there is a change in a resident's condition, which was not adhered to in these cases.
Failure to Obtain Physician Orders and Conduct Post-Elopement Assessment
Penalty
Summary
The facility failed to obtain physician orders for pacemaker checks for two residents, which is a requirement according to the facility's policy and the residents' care plans. One resident, who was cognitively intact and had diagnoses including congestive heart failure and atrial fibrillation, did not have documented evidence of a physician's order for pacemaker checks. Similarly, another resident, also cognitively intact with coronary artery disease and a history of stroke, lacked documented physician orders for pacemaker checks. Interviews with the Director of Nursing confirmed the absence of these orders, which were necessary as per the facility's policy. Additionally, the facility did not ensure that a registered nurse completed an assessment after an elopement incident involving another resident. This resident, who was cognitively intact and required maximum assistance for daily care tasks, was found outside the facility without a coat. Upon returning, there was no documented evidence that the resident was assessed by a registered nurse, as required by the facility's policy for missing residents. The Director of Nursing confirmed that the assessment was not conducted as per the policy.
Failure to Complete Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that neurological checks were completed following an unwitnessed fall for one of the residents reviewed. According to the facility's policy for unwitnessed falls, neurological checks should be conducted to assess sensory neuron and motor responses to determine if the nervous system is impaired. The policy specifies that these checks should be performed every 15 minutes for two hours, every 30 minutes for two hours, every hour for four hours, and then every eight hours until 72 hours have passed. However, for Resident 99, who had an unwitnessed fall on July 10, 2024, the neurological checks were not completed as required by the policy. Resident 99, who has a diagnosis of Parkinson's disease and requires substantial assistance with daily care needs, experienced an unwitnessed fall at her recliner. The nurse's note indicated that neurological checks were to be completed, and the flow sheet for these checks was initiated. While the checks were completed per policy until the second shift on July 11, 2024, there was no further documentation of the 8-hour checks being completed. An interview with the Director of Nursing confirmed that these checks should have been conducted after the unwitnessed fall, indicating a lapse in following the established protocol.
Failure to Implement Physician-Ordered Pressure Relief Devices
Penalty
Summary
The facility failed to ensure that pressure relief devices were in place as ordered by the physician for a resident identified as at risk for pressure injuries. The resident, who was cognitively impaired and required assistance for daily care tasks, had medical diagnoses including stroke, coronary artery disease, and high blood pressure. The care plan specified the use of an E-Z flex splint on the left hand and a left elbow comfy splint for four hours per shift to prevent skin breakdown. However, during observations, it was noted that the resident was not wearing the left elbow splint as ordered, although it was present in the room. Interviews with the Director of Therapy and the Director of Nursing confirmed that the splints were necessary to promote skin integrity and should have been in place according to the physician's orders. The Director of Therapy mentioned that the resident sometimes refused to wear the splints, but there was no documented evidence of refusal in this instance. This oversight was a violation of the facility's policy on pressure injury care and treatment, as well as a failure to comply with the physician's orders.
Failure to Document and Provide Tracheostomy Care
Penalty
Summary
The facility failed to ensure that physician's orders for tracheostomy care were followed for a resident, leading to a deficiency. The facility's policy required tracheostomy care to be provided as per physician's orders and documented in the electronic Medication Administration Record (eTAR) Treatment Page. However, a review of the records for a resident with a tracheostomy and chronic respiratory failure revealed that there was no documented evidence of tracheostomy care being provided on specific dates in March and April 2024. Additionally, there was no documentation of the application of a tracheostomy sponge as ordered by the physician. The resident involved was cognitively intact and required limited assistance with daily care needs. The resident had a tracheostomy related to diphtheria and chronic respiratory failure, with physician's orders for daily tracheostomy care and sponge application. Despite these orders, the facility's records did not show that the care was provided on certain days, which was confirmed by the Assistant Director of Nursing. This lack of documentation and adherence to physician's orders constituted a failure in providing necessary nursing services as per the regulations.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aide performance evaluations were completed at least annually for two of the five nurse aides reviewed. Specifically, Nurse Aides 5 and 6, who were hired over a year ago, did not have performance evaluations completed in the past year. This was confirmed through a review of personnel files and staff interviews. The Director of Nursing was unable to provide documentation to show that these evaluations had been conducted, confirming the deficiency during an interview.
Ineffective QAPI Committee Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in consecutive surveys. The deficiencies included problems with assessment coding, developing and revising residents' care plans, adherence to professional standards, and overall quality of care. Despite having plans of correction in place from a previous survey, the facility was unable to maintain compliance with the cited nursing home regulations. The current survey revealed that the QAPI committee was ineffective in implementing and maintaining the necessary corrective actions. Specific deficiencies were noted under F641 for assessment coding, F656 and F657 for care plan development and revision, F658 for professional standards, and F684 for quality of care. These findings indicate that the audits and monitoring systems intended to ensure compliance were not successful, leading to repeated citations in these areas.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 179 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hollidaysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollidaysburg Veterans Home | 0.9 mi | ★★★★★ | 12 | 0 |
| Lutheran Home At Hollidaysburg | 1 mi | ★★★★★ | 15 | 0 |
| Presbyterian Homes-presby | 1.6 mi | ★★★★★ | 7 | 0 |
| Hilltop Healthcare And Rehabilitation Center | 2.8 mi | ★★★★★ | 13 | 0 |
| Maybrook Hills Rehabilitation And Healthcare Cente | 4.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.