Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garvey Manor during CMS and state inspections, most recent first.
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 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.
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What surveyors actually found near you
We read the 192 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
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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 | ★★★★★ | 6 | 0 |
| Lutheran Home At Hollidaysburg | 1 mi | ★★★★★ | 14 | 0 |
| Presbyterian Homes-presby | 1.6 mi | ★★★★★ | 8 | 0 |
| Hilltop Healthcare And Rehabilitation Center | 2.8 mi | ★★★★★ | 14 | 0 |
| Maybrook Hills Rehabilitation And Healthcare Cente | 4.7 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.