Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Green Valley Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
Food storage and temperature log deficiencies were identified when staff failed to label and date opened beverages, dairy products, bologna, and thawed nutritional shakes in the dietary areas. Surveyors also observed that kitchen staff did not obtain or record meal temperatures, and the facility could not provide a breakfast food temperature log; the RD and FSD confirmed temperatures must be documented for each meal.
The facility failed to ensure MDS assessments accurately reflected two residents’ status. One resident with schizophrenia and cataracts was incorrectly coded for PASRR status and corrective lens use despite records and interview evidence showing level II PASRR involvement and use of glasses. Another resident with schizophrenia was also incorrectly coded for PASRR status, and the MDS misidentified antiplatelet use as anticoagulant use even though the MAR showed Aspirin 81 mg during the lookback period. The RNAC confirmed the MDS entries were inaccurate.
An LPN/RN medication administration failure involved two residents whose BP-dependent orders were not followed. One resident with HTN received Clonidine multiple times when systolic BP was below the hold parameter, and another resident with CHF and chronic AFib received Midodrine multiple times when systolic BP was above the hold parameter. The DON confirmed the medications were given outside the physician-ordered parameters.
Failure to Follow Physician Order Hold Parameters: The facility failed to ensure nurses followed physician order hold parameters for medications and failed to identify recurring medication administration errors through QAPI monitoring. A resident with HTN and osteomyelitis received Lisinopril and Metoprolol outside ordered BP/HR limits, and two residents with CHF/atrial fibrillation and HTN/hypovolemic shock received Midodrine when systolic BP exceeded the ordered hold parameters. The DON and NHA confirmed the recurring deficient practice.
Laundry room linen handling failed to keep soiled and clean laundry separated as required by facility policy. An observation found multiple bags of soiled laundry stored directly next to resident clean laundry in the same area, and the IP and DON both confirmed that clean and soiled laundry were not stored separately.
Failure to Offer Recommended Flu and Pneumococcal Vaccinations: The facility did not document that two residents were offered or received recommended pneumococcal and annual influenza immunizations, and there was no record of refusal or contraindication. One resident had type 2 DM and the other had schizophrenia; both had prior PCV13 and influenza vaccines, but the facility could not show that the additional pneumococcal dose or the annual flu vaccines were offered for later seasons.
A resident with schizophrenia and cataracts reported ongoing blurry vision and said she needed new glasses, but staff did not ensure timely vision treatment or arrange evaluation by a vision specialist. Her last documented visual acuity exam was over a year earlier, and the DON could not provide evidence of a comprehensive eye exam or that she had been scheduled for evaluation until survey inquiries were made.
Failure to monitor and address significant weight loss: A resident with HTN, major depressive disorder, and protein-calorie malnutrition had repeated weight fluctuations and a 12.7% body weight loss, yet there were no active orders for routine or increased weight monitoring at the time of survey. RD notes documented significant weight loss and variable intake, but no dietary changes were recommended, and the record lacked documentation that the attending MD or resident was notified of the loss or that the lack of nutritional interventions was reviewed with the MD.
The facility failed to provide an ongoing program of activities to meet residents' needs, as three residents expressed concerns about the lack of activities on Sundays and Mondays. The activity calendar and staffing records confirmed no scheduled activities or assigned staff on these days. Residents had previously raised these issues during council meetings, but no action was taken.
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in nutritional care. One resident experienced a 12.4 lb. weight loss over nine days, and another lost 38 lbs. over several months. Required reweights were not conducted, and physicians were not notified. Additionally, recommended nutritional interventions were not implemented, and there was a discrepancy in fluid restriction status.
A physician failed to act on pharmacist-identified medication irregularities for three residents with various mental health diagnoses. Despite multiple medication regimen reviews, the facility lacked documentation of the pharmacist's recommendations and the physician's responses, as confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment was improperly restrained using furniture to create a makeshift playpen, without a physician's order or consent. The facility failed to follow its policies on restraint utilization and resident rights, leading to a deficiency.
A facility failed to ensure accurate MDS assessments for a resident with paranoid schizophrenia and major depressive disorder. Despite a positive PASRR Level 1 screen and confirmation of eligibility for Level II services, the MDS assessment inaccurately reported the resident's mental illness status. This was confirmed by the RN assessment coordinator.
A facility failed to follow physician orders for a resident's PICC line management. The resident, with a PICC line for antibiotic therapy due to knee issues, had orders for specific antibiotics and saline flushes. However, the Medication Administration Record showed the PICC line was not consistently flushed as required, confirmed by the DON.
A resident with congestive heart failure did not receive proper maintenance of their oxygen equipment, as the facility failed to change the oxygen tubing weekly per policy. Observations over several days showed the tubing was not replaced, and the DON confirmed the oversight.
A facility failed to maintain a system of records for controlled drugs, specifically Oxycodone, for a resident with diabetes and prostate cancer. The resident was discharged with 10 Oxycodone tablets, but there was no documented accountability record as required by facility policy. The DON confirmed the lack of documentation, which is necessary to prevent unauthorized use and ensure accurate accounting.
A facility failed to document the clinical rationale for increasing an antipsychotic medication for a resident with severe cognitive impairment. Despite a psychiatric team meeting, there was no evidence of alternative treatments considered or resident involvement in the decision-making process. The DON confirmed the lack of documentation and the facility's responsibility to prevent unnecessary psychotropic medication.
The facility failed to maintain proper signage for the emergency generator's remote manual stop station, as observed during a survey. The absence of identifying signage was confirmed by the Administrator and Maintenance Director, indicating non-compliance with NFPA standards.
The facility was found deficient in maintaining proper signage for the Fire Department Connection of the sprinkler system. An observation revealed the absence of identifying signage, which was confirmed during an interview with the Administrator and Maintenance Director.
A resident with cerebral ischemia and dementia, requiring assistance from two staff members for transfers, sustained a sprained ankle when a nurse aide transferred the resident alone. The incident occurred during a transfer from the toilet to a wheelchair, resulting in the resident's left knee giving out and subsequent fall. The injury led to pain, swelling, and a decline in mobility and independence in activities of daily living. Interviews confirmed the failure to follow the care plan and physician orders for safe transfers.
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. The current food service director is enrolled in an online course to become a certified dietary manager and is not yet qualified. The facility employs a part-time consultant dietitian who works approximately four hours per week. The previous full-time qualified food service director left the facility, and the position has not been filled.
The facility failed to maintain acceptable practices for food storage and service, including the use of unpasteurized eggs and improper dating of food items in the resident pantry refrigerator. These actions increased the risk of food-borne illness.
The facility failed to accommodate a resident with COPD and a bariatric wheelchair, preventing her from participating in activities due to the narrow width of the Activity Room door. Despite being aware of the issue and having a pending work order, the problem was not resolved, leading to the resident's inability to engage in her preferred activities.
The facility failed to follow its abuse prohibition procedures for screening and training a rehired nurse aide. The employee was rehired without an employment application, background check, contact with previous employers, or verification of certification. Additionally, the employee did not receive the required orientation training.
A resident who required two-person assistance for transfers was transferred by a single nurse aide, resulting in a sprained ankle. The incident was not reported to the State Survey Agency within the required time frames, violating the facility's abuse prohibition policy.
A resident with multiple diagnoses, including depression and dementia, expressed a desire to harm herself, but the facility failed to provide therapeutic social services or follow up on the resident's distress. The Director of Social Services was unaware of the statement, and no documentation of therapeutic intervention was found.
The facility failed to maintain accurate and complete clinical records for a resident with congestive heart failure, diabetes, chronic kidney disease, and GERD, who experienced weeping in her left lower extremity. Despite the resident's condition being noted, there was a lack of timely and accurate documentation regarding the facility's response and communication with the physician.
Food Storage and Temperature Log Deficiencies
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food and failed to record and maintain food temperature logs. During the initial tour of the dietary department with the Food Service Director, surveyors observed opened food and beverage items in the walk-in refrigerator and resident food pantry that had no open or discard dates, including almond milk, thickened dairy beverages, thickened cranberry juice, thickened apple juice, and sweet bologna. The Food Service Director confirmed that the sweet bologna should be discarded 3 days after opening, and the report also noted 16 thawed 4-ounce nutritional shakes with no thaw or discard date, despite manufacturer instructions that thawed supplements be used within 14 days. The facility policies reviewed required all open items to be labeled and dated, and required food temperatures to be taken and properly recorded for each meal, with hot food held and served at at least 130 degrees Fahrenheit. During lunch tray line observation, kitchen staff did not obtain or record food temperatures before meal service, and the facility could not provide a food temperature log for the breakfast meal. When temperatures were later taken, chicken was 160 degrees Fahrenheit, vegetable 140 degrees Fahrenheit, and pasta 141 degrees Fahrenheit. The Registered Dietitian and Food Service Director confirmed that food temperatures are required to be obtained and documented for each meal.
Inaccurate MDS Assessments for PASRR Status, Vision, and Medication Coding
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of two residents. The Long-Term Care Facility RAI User’s Manual requires the assessment to accurately reflect the resident’s status and to include direct observation and communication with the resident and direct care staff on all shifts. Survey review found that the facility’s MDS documentation for Residents 16 and 34 did not match information in the clinical record and was confirmed as inaccurate by the RNAC. Resident 16 was admitted with diagnoses including schizophrenia and cataracts. A Quarterly MDS dated [DATE] identified the resident as cognitively intact with a BIMS score of 15, and a Significant Change in Status MDS dated [DATE] indicated the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. However, the clinical record contained a February 20, 2018 letter from the Pennsylvania Department of Human Services OMHSAS stating the resident had evidence of a mental health condition that met criteria for OMHSAS review and that the facility must provide or arrange mental health services. The record also showed a community provider glasses adjustment note dated December 11, 2025, and the resident stated during interview that she had vision problems and needed new glasses, while the MDS dated October 18, 2025, stated she did not use corrective lenses. Resident 34 was admitted with schizophrenia. An Annual MDS dated [DATE] stated the resident was not currently considered by the state-level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, although the clinical record contained a February 23, 2018 OMHSAS letter stating the resident had evidence of a mental health condition meeting criteria for OMHSAS review and that the facility must provide or arrange mental health services. In addition, a Quarterly MDS dated [DATE] incorrectly coded Section N0415 by indicating the resident took an anticoagulant during the seven-day lookback and did not take an antiplatelet medication, while the medication record showed the resident received Aspirin 81 mg on seven days during that lookback period and no anticoagulant was documented. The RNAC confirmed the MDS entries for Residents 16 and 34 were not accurate, and the DON was informed of the findings.
Medication Administered Outside Physician-Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses administered medications according to physician orders for two residents. One resident had diagnoses including hypertension and osteomyelitis, and a physician order directed staff to give Clonidine HCl 0.1 mg by mouth twice daily and hold it if systolic blood pressure was less than 120 mm/Hg. The MAR showed Clonidine was administered 9 times when the documented systolic blood pressure was below 120 mm/Hg, including readings of 110/68, 112/68, 101/60, 113/98, 112/96, 106/66, 110/80, 110/70, and 98/58 mm/Hg. Another resident had diagnoses including CHF and chronic atrial fibrillation, and a physician order directed staff to administer Midodrine HCl 2.5 mg by mouth three times daily and hold it if systolic blood pressure was greater than 120 mm/Hg. The MAR showed Midodrine was administered 7 times when the documented systolic blood pressure was above 120 mm/Hg, including readings of 128/68, 128/68, 123/60, 130/68, 122/63, 145/36, and 121/62 mm/Hg. During interview, the DON confirmed nursing staff failed to follow acceptable standards of nursing practice during medication administration because the medications were given outside the physician-ordered parameters.
Failure to Follow Physician Order Hold Parameters
Penalty
Summary
The facility failed to ensure its QAPI program identified and addressed recurring deficient practices related to nursing services and compliance with physician orders. The report states that after a prior citation involving medication administration outside hold parameters, the facility’s QAPI documentation did not show that the same type of errors were identified through monitoring, trended, analyzed for root cause, or addressed with sustained corrective action. The Director of Nursing and Nursing Home Administrator confirmed during interview that the facility failed to prevent recurrence of similar quality deficiencies involving licensed nurses properly evaluating and providing nursing care according to physician orders. For Resident 1, the clinical record showed diagnoses including hypertension and osteomyelitis. A physician ordered Lisinopril 10 mg daily with instructions to hold if systolic blood pressure was less than 110 mm/Hg, yet the January 2026 MAR showed the medication was given when the documented blood pressure was 109/52 mm/Hg. The same resident also had an order for Metoprolol Tartrate 25 mg twice daily to be held if systolic blood pressure was less than 100 mm/Hg or heart rate was less than 60 beats per minute, but the February 2026 MAR showed the medication was administered with no documented blood pressure at the time and a heart rate of 68 beats per minute. For Resident 2, who had diagnoses including CHF and chronic atrial fibrillation, a physician ordered Midodrine HCl 2.5 mg every eight hours with instructions to hold if systolic blood pressure was greater than 120 mm/Hg. The January and February 2026 MARs showed the medication was administered when blood pressure readings were 129/76 mm/Hg, 122/60 mm/Hg, and 126/64 mm/Hg. For Resident 3, who had diagnoses including hypertension and hypovolemic shock, a physician ordered Midodrine HCl 5 mg every eight hours with instructions to hold if systolic blood pressure was greater than 120 mm/Hg, yet the January 2026 MAR showed the medication was administered when blood pressure readings were 126/64 mm/Hg and 122/80 mm/Hg.
Laundry Room Failed to Separate Soiled and Clean Linen
Penalty
Summary
The facility failed to ensure personnel handled, stored, processed, and transported linens in a manner that prevented the spread of infection in one laundry room. The facility policy titled Linen Handling, Storage, Process, and Transportation stated that soiled laundry was to be treated as contaminated, handled as little as possible, and stored separately from clean laundry, with soiled linen clearly separated from areas where clean linen was handled. During an observation in the laundry room, nine blue plastic bags containing soiled laundry were found stored next to resident clean laundry, less than 1 foot apart. The Infection Preventionist confirmed that the soiled laundry was stored directly adjacent to the clean laundry and that the clean laundry was not stored in a separate area from the soiled laundry. During an interview, the DON confirmed that resident soiled laundry and clean laundry were not stored separately and stated that the facility would implement a procedural change.
Failure to Offer Recommended Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and/or provided recommended influenza and pneumococcal immunizations for two of five residents reviewed. Facility policies stated that residents would be offered pneumococcal vaccination in accordance with CDC standards and that residents in the facility during influenza season would be included in the annual influenza immunization program. The CDC Adult Vaccine Schedule referenced in the report indicated that adults 50 years or older who previously received PCV13 should be offered an additional pneumococcal vaccine dose to complete the series. Resident 6, who had a diagnosis of type 2 diabetes, had documentation of one PCV13 dose and one influenza vaccine, but there was no documented evidence that the facility offered the resident or the resident representative the recommended additional pneumococcal vaccination or annual influenza vaccination for the 2024 or 2025 influenza season, and no documentation of refusal or contraindication. Resident 16, who had a diagnosis of schizophrenia, also had documentation of one PCV13 dose and one influenza vaccine, but there was no documented evidence that the facility offered the recommended additional pneumococcal vaccination or annual influenza vaccination for the 2024 or 2025 influenza season, and no documentation of refusal or contraindication. The Infection Preventionist confirmed the facility could not provide documented evidence that either resident was offered or provided the recommended immunizations or that refusals were obtained.
Failure to Ensure Vision Services and Assistive Devices
Penalty
Summary
The facility failed to ensure Resident 16 received proper treatment and assistive devices to maintain vision and failed to arrange for treatment by a professional specializing in vision assistive devices as needed. Resident 16 was admitted with diagnoses including schizophrenia and cataracts, and a Quarterly MDS dated October 18, 2025, showed she was cognitively intact with a BIMS score of 15. Her last documented visual acuity evaluation was on November 21, 2024. Clinical notes showed Resident 16 reported blurry vision on November 28, 2025, and again on December 2, 2025. A community provider note dated December 11, 2025, documented that her eyeglasses were adjusted for comfort. During an interview on December 16, 2025, Resident 16 stated she had been having problems with her vision, needed new glasses, and had been reporting the issue to staff without anything being done. A progress note later that day documented complaints with vision and a referral to the community provider for the next visit. The DON was unable to provide documented evidence of a comprehensive eye examination within the last year and could not provide evidence that Resident 16 had been scheduled for evaluation for blurry vision until survey inquiries were made.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to assess, evaluate, and monitor the nutritional parameters of a resident with significant weight loss. The resident was admitted with hypertension and major depressive disorder, was cognitively intact with a BIMS score of 14, and had a care plan identifying protein-calorie malnutrition with instructions to monitor, record, and report signs and symptoms of malnutrition, including weight loss, to the physician. The resident’s documented weights showed repeated fluctuations and a progressive decline over time, including a drop from 121 pounds in early October to 105.6 pounds by December 18, representing a 15.4-pound loss and 12.7% body weight loss since September 23. RD progress notes documented triggers for significant weight gain and loss, variable intake, and later continued significant weight loss, but no dietary changes were recommended. The final RD note stated the resident had C. difficile and anticipated weight improvement as the infection resolved, with no dietary changes recommended. At the time of survey, there were no active physician orders for routine or increased weight monitoring, and a new weekly weight order was only placed after surveyor inquiry. The record contained no documented evidence that the attending physician or the resident was notified of the significant weight loss, and there was no documentation explaining why interventions were not recommended by the RD or that the lack of nutritional interventions was reviewed with or agreed upon by the attending physician.
Lack of Scheduled Activities on Sundays and Mondays
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents, as evidenced by concerns raised by three out of four residents during a group interview. The residents expressed dissatisfaction with the lack of activities on Sundays and Mondays, which was confirmed by a review of the activity calendar and staffing documentation showing no scheduled activities or assigned activity staff on these days throughout February 2025. The residents had previously raised these concerns during Resident Council meetings, but no action had been taken to address the issue. Resident 4, who is cognitively intact, expressed a preference for hymn singing on Sundays and desired at least one program on Sundays and Mondays. Resident 6, with moderate cognitive impairment, and Resident 8, also cognitively intact, indicated an interest in additional bingo activities and leading activities themselves. The Nursing Home Administrator confirmed the absence of activity staff on Sundays and Mondays and acknowledged the facility's responsibility to ensure residents' needs and preferences are met, as per 28 Pa. Code 201.29 (a) Resident rights.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in nutritional care. Resident 36 experienced a 12.4 lb. weight loss over nine days and a subsequent 7 lb. weight loss, yet the facility did not conduct required reweights or notify the physician and resident representative as per their policy. The Director of Nursing confirmed these lapses, acknowledging that the weight loss was not communicated to the physician each time it was noticed. Resident 20 also experienced a significant weight loss of 38 lbs. over several months. Despite a dietary referral and recommendations for daily weights and nutritional interventions, the facility did not conduct reweights or implement the recommended health shake. Additionally, there was a discrepancy in the resident's fluid restriction status, which had been discontinued but was still referenced in dietary notes. The Director of Nursing confirmed these failures, including the lack of communication with the physician and resident representative regarding the weight loss.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The deficiency involves the failure of a physician to act upon pharmacist-identified irregularities in the medication regimens of three residents. Resident 11, who was admitted with diagnoses including anxiety disorder, major depressive disorder, and dementia, had medication regimen reviews conducted on multiple occasions. Despite the pharmacist making recommendations during these reviews, the facility was unable to provide documentation of these recommendations or any response from the physician. Similarly, Resident 24, diagnosed with dementia and major depressive disorder, and Resident 4, diagnosed with paranoid schizophrenia and major depressive disorder, also had medication regimen reviews where the pharmacist made recommendations. However, the facility failed to document these recommendations or any physician response. The Nursing Home Administrator confirmed the lack of documentation for the pharmacist's recommendations and the physician's actions, which constitutes a deficiency under the relevant Pennsylvania Code sections.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required to treat a medical symptom. The resident, who was severely cognitively impaired and had a history of osteoarthritis and acute respiratory failure, was found on the floor near her bed and later placed in a makeshift playpen created by surrounding her with furniture. This action was taken without a physician's order, consent from the resident or her representative, or documented evidence that less restrictive measures had been attempted and failed. The resident's care plan included interventions for altered sleep and wake cycles, communication problems, and behavior issues related to suicidal ideation. Despite these interventions, the resident was found on the floor and later placed in a wheelchair at the nurse's station. When the resident expressed discomfort and requested to return to bed, she was instead placed on a mattress on the floor in the common area, surrounded by furniture to prevent her from moving. Witness statements from staff members confirmed the use of furniture as a restraint, with one staff member describing the action as abusive. The facility's Director of Nursing and Nursing Home Administrator acknowledged the lack of a documented physician order, care plan intervention, or consent for the use of the furniture as a restraint. The facility's policies on restraint utilization and resident rights were not followed, leading to the deficiency.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident. The resident in question was admitted with diagnoses of paranoid schizophrenia and major depressive disorder. A review of the resident's Pennsylvania Preadmission Screening Resident Review Identification (PASRR) Level 1 form indicated a positive screen for serious mental illness, necessitating a Level II evaluation. A subsequent letter from the Pennsylvania Department of Human Services confirmed the resident's eligibility for Level II services, requiring the facility to provide or arrange for mental health services. However, the significant change MDS assessment inaccurately reported that the resident was not considered a state Level II PASRR for serious mental illness. This inaccuracy was confirmed during an interview with the registered nurse assessment coordinator.
Failure to Follow PICC Line Management Orders
Penalty
Summary
The facility failed to provide person-centered care and adhere to physician orders for the management of a PICC line for a resident. The resident, who was admitted with a PICC line for antibiotic therapy due to a right total knee replacement and a left knee infection, had specific physician orders for the administration of Vancomycin HCL and Cefazolin Sodium. Additionally, there was an order for a Normal Saline flush to be used intravenously every shift before and after the administration of IV antibiotics. Upon review of the resident's February 2025 Medication Administration Record, it was found that the PICC line was not consistently flushed before and after the administration of each IV antibiotic as per the physician's orders and facility policy. This was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documented evidence for the required flushing of the PICC line. This deficiency was noted under the 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Maintain Oxygen Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in accordance with its policy, affecting one resident who required oxygen therapy. The facility's policy, last reviewed on December 14, 2024, mandates that oxygen tubing and humidifier bottles be changed weekly to ensure optimal functioning. However, observations revealed that the oxygen tubing attached to the resident's oxygen concentrator was not replaced as required. The tubing was dated January 20, 2025, and remained unchanged during observations on February 25, 26, and 27, 2025. The resident involved had been admitted with a diagnosis of congestive heart failure and had physician orders for oxygen therapy to manage shortness of breath. Despite the resident's need for respiratory support, the facility did not adhere to its policy of weekly tubing changes. The Director of Nursing confirmed the oversight, acknowledging that the tubing had not been replaced per the facility's guidelines, thus failing to maintain the resident's oxygen equipment properly.
Failure to Document Controlled Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not maintaining a system of records for the receipt and disposition of controlled drugs, specifically Oxycodone, for one resident. The facility's policy requires that all controlled medications be accounted for, inventoried, and destroyed in the presence of two licensed clinicians, with documentation on the accountability record. However, for Resident 43, who was admitted with diagnoses including diabetes and prostate cancer, there was no documented evidence of a controlled medication accountability record for the Oxycodone 2.5 mg tablets prescribed for pain or dyspnea. Upon discharge, Resident 43 was sent home with medications, including 10 Oxycodone tablets, but the facility failed to provide documentation of the accountability record for these controlled medications. An interview with the Director of Nursing confirmed the absence of this documentation, which is required to prevent unauthorized use or misappropriation and ensure accurate accounting and disposition of controlled drugs.
Lack of Documentation for Antipsychotic Medication Increase
Penalty
Summary
The facility failed to ensure proper documentation and justification for the increase of an antipsychotic medication for a resident diagnosed with a psychotic disorder and dementia. The resident, who was admitted with severe cognitive impairment, had a care plan addressing potential physical aggression and impaired cognitive function. Despite a psychiatric interdisciplinary team meeting where new recommendations were made, the clinical record lacked documented evidence of the clinical rationale for increasing the resident's antipsychotic medication, alternative treatment options considered, or involvement of the resident or their representative in the decision-making process. The Director of Nursing confirmed the absence of documentation supporting the rationale for the dosage increase and acknowledged the facility's responsibility to ensure residents are free from unnecessary psychotropic medication. The medication administration records showed that the resident received the additional dose of Quetiapine Fumarate daily for a month, but there was no evidence of a clinical rationale or discussion of alternative interventions. This deficiency was identified through clinical record review and staff interviews, highlighting a failure in the facility's medication management practices.
Emergency Generator Signage Deficiency
Penalty
Summary
The facility failed to maintain proper signage for the emergency generator's remote manual stop station. During an observation conducted on February 12, 2025, at 1:05 PM, it was noted that the stop station lacked identifying signage. This deficiency was identified as affecting the entire component of the emergency generator system. An interview conducted during the exit conference with the Administrator and Maintenance Director on the same day confirmed the absence of the required signage. The lack of signage was acknowledged by the facility's representatives, indicating a failure to comply with the necessary maintenance and testing protocols as outlined in NFPA standards.
Plan Of Correction
The maintenance has installed a sticker identifying the remote manual stop station for the emergency generator. The NHA and maintenance director will tour the facility and grounds to identify any other locations which may need additional or new signage to maintain compliance. The NHA and maintenance director will review life safety regulations for signage to ensure that the facility is in compliance. The maintenance director will audit the sticker weekly with his generator checks to ensure the sticker remains in place. Results of the audit will be forwarded to the QAPI committee for review.
Deficiency in Fire Department Connection Signage
Penalty
Summary
The facility failed to maintain proper signage for the Fire Department Connection associated with the installed sprinkler system. During an observation on February 12, 2025, at 12:55 PM, it was noted that the Fire Department Connection lacked identifying signage. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the exit conference on the same day at 1:30 PM.
Plan Of Correction
The maintenance director has installed a reflective sign identifying the location of the fire department hookup. The NHA and maintenance director will tour the facility and grounds to identify any other locations which may need additional or new signage to maintain compliance. The NHA and maintenance director will review life safety regulations for signage to ensure that the facility is in compliance. The maintenance director will audit the fire department connection sign with his generator checks to ensure the sign remains in place. Results of the audit will be forwarded to the QAPI committee for review.
Inadequate Transfer Assistance Leads to Resident Injury and Decline
Penalty
Summary
The facility neglected to provide the necessary care and services to prevent physical harm to Resident 33, resulting in a sprained ankle and subsequent decline in activities of daily living. Resident 33, admitted with diagnoses of cerebral ischemia and dementia, had a care plan indicating the need for assistance from two staff members for transfers due to impaired balance and cognitive impairment. Despite physician orders and care plans specifying the requirement for two staff members during transfers, Employee A1, a nurse aide, transferred Resident 33 alone, leading to the ankle injury on February 29, 2024. The incident occurred during a transfer from the toilet to a wheelchair when Resident 33's left knee gave out, causing Employee A1 to lower the resident to the floor. Subsequent assessments revealed left ankle tenderness, edema, and pain, with the resident unable to bear weight on the ankle. Despite receiving Tylenol for pain management, Resident 33 continued to experience ankle pain and required a Hoyer lift for transfers until the swelling decreased. Physical therapy sessions post-injury noted the resident's complaints of left foot/ankle pain impacting transfer and ambulation abilities, leading to a decline in mobility and independence in activities of daily living. Interviews with Resident 33's family member and the Nursing Home Administrator confirmed the facility's failure to ensure the resident's safety, with Employee A1 neglecting to follow the care plan and physician orders for safe transfers. The family member expressed concerns about the setback in Resident 33's physical rehabilitation post-injury, affecting the resident's ability to walk and delaying potential discharge home. The Nursing Home Administrator acknowledged the deficiency in ensuring Resident 33's safety and the subsequent decline in the resident's activities of daily living due to the sprained ankle caused by inadequate transfer assistance.
Failure to Employ Qualified Food Service Director
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. An interview with the food service director (FSD) revealed that she was currently enrolled in an online course to become a certified dietary manager and was not yet qualified for the position according to regulatory criteria. The facility employed a part-time consultant dietitian who worked approximately four hours per week. Review of monthly time sheets confirmed this arrangement. The nursing home administrator confirmed that the previous full-time qualified food service director's last day of employment was on October 20, 2023, and that the facility did not currently employ a full-time qualified food service director.
Failure to Maintain Food Storage and Service Standards
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the food and nutrition services department, it was observed that two cases of fresh shell eggs, which were not pasteurized, were present on a shelf in the walk-in refrigerator. The food service director (FSD) confirmed that these unpasteurized eggs were being used to serve dippy eggs and that they were ordered by mistake instead of pasteurized shell eggs from the food supplier. This practice is against CMS guidance and increases the risk of residents contracting Salmonella Enteritis. Further observations in the resident pantry refrigerator revealed several food storage and sanitation concerns. A thawed 4-ounce nutritional shake and a 10-gallon plastic bag containing 4-ounce nutritional shakes were not dated with a thaw or discard date, despite manufacturer instructions to use them within 14 days after thawing. Additionally, two plastic storage containers of applesauce, two 46-ounce bottles of thickened juice, and a 60-ounce bottle of apple juice were opened but not dated. A spill was also observed under the plastic pull-out crisper drawer of the refrigerator. The FSD confirmed that food and beverages were to be stored and thawed according to acceptable practices and that the food and nutrition services department and resident pantry were to be maintained in a sanitary manner to prevent potential contamination.
Failure to Accommodate Resident's Participation in Activities
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 41, who has chronic obstructive pulmonary disease (COPD) and uses a bariatric wheelchair with a 40-inch width. Despite being cognitively intact and having a care plan that included participation in activities such as bingo, arts and crafts, and spiritual services, Resident 41 was unable to attend many activities because her wheelchair could not fit through the 36-inch wide Activity Room door. This issue was confirmed by the Director of Maintenance, who had been aware of the problem and had a pending work order to address it, which had not been completed by the time of the survey. Resident 41 expressed frustration during an interview, stating that she had to sit in the hallway to listen to spiritual services because her wheelchair would not fit through the door. The Nursing Home Administrator confirmed that the facility failed to make reasonable accommodations to allow Resident 41 to participate in her chosen activities. The deficiency was identified under 28 Pa. Code 201.29 (a) Resident rights.
Failure to Implement Abuse Prohibition Procedures for Rehired Employee
Penalty
Summary
The facility failed to implement their established abuse prohibition procedures for fully screening and training one employee out of five reviewed. Specifically, Employee 1, a nurse aide, was rehired on December 23, 2023, without documented evidence of an employment application, a PA State Police criminal background check, contact with previous employers to screen for history of abuse or mistreatment, or verification of the employee's nurse aide certification. Additionally, there was no documentation that Employee 1 received orientation training, including abuse training, as required by the facility's policy. An interview with the Business Office Manager confirmed that the facility did not have an application packet for Employee 1's rehire and that the necessary background checks and verifications were not completed. The Business Office Manager also confirmed that Employee 1 did not receive the required orientation training upon rehire. This failure to follow established procedures for screening and training employees led to the deficiency identified in the report.
Failure to Timely Report Resident Neglect
Penalty
Summary
The facility failed to timely report an instance of resident neglect to the State Survey Agency. The incident involved Resident 33, who required the assistance of two staff members for transfers. On February 29, 2024, Employee A1, a nurse aide, attempted to transfer Resident 33 alone, resulting in the resident's left knee giving out and her being lowered to the floor. Initially, no injuries were reported, but later that day, Resident 33 experienced left ankle tenderness, edema, and pain, and was unable to bear weight on her ankle. A subsequent facility incident report confirmed that Employee A1 was aware of the two-person transfer requirement but chose to perform the transfer alone, leading to Resident 33's sprained ankle. The incident was not reported to the State Survey Agency within the required time frames. The facility's abuse prohibition policy mandates that all incidents of suspected neglect be thoroughly investigated and reported to the Pennsylvania Department of Health within five calendar days. Despite this policy, the neglect incident involving Resident 33 was not reported in a timely manner. The Nursing Home Administrator confirmed that the facility staff failed to ensure that Resident 33 received the necessary services to avoid physical harm and acknowledged the delay in reporting the neglect to the State Survey Agency.
Failure to Provide Therapeutic Social Services
Penalty
Summary
The facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of a resident diagnosed with malignant neoplasm of the colon, COPD, depression, and dementia. The resident, who was moderately cognitively impaired with a BIMS score of 10, expressed a desire to harm herself by asking for scissors or a razor to slit her wrists. This statement of distress was documented in a behavior note, but there was no follow-up or provision of therapeutic social services documented in the resident's clinical record. An interview with the Director of Social Services revealed that she was unaware of the resident's statement and had not provided any follow-up or therapeutic social services. The Nursing Home Administrator confirmed the lack of documented evidence of therapeutic social services being provided to the resident following her statement of wanting to harm herself. This failure to address the resident's expressed distress constitutes a deficiency in providing medically-related social services to help the resident achieve the highest possible quality of life.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records consistent with professional standards of practice by not timely and accurately documenting the response to a change in a resident's condition. Resident 40, who was admitted with diagnoses including congestive heart failure (CHF), diabetes, chronic kidney disease, and gastro-esophageal reflux disease (GERD), experienced weeping in her left lower extremity. Despite the resident's condition being noted in nursing documentation, there was a lack of timely and accurate documentation regarding the facility's response and communication with the physician about the resident's condition. On March 23, 2024, a nursing note indicated that the resident's left lower leg was weeping, but there was no immediate follow-up or documentation of physician notification. By March 26, 2024, the resident's condition had not improved, and she expressed concerns about her weeping legs and recent weight gain. The resident was unsure if the physician was aware of her condition. A nursing note later that day mentioned the physician was informed, but there was no corresponding physician progress note to confirm this. The Director of Nursing (DON) acknowledged the lack of documentation regarding the physician's visit and orders for the resident's leg dressings. The resident continued to express concerns about her condition, and the facility's failure to document timely and accurate responses to the resident's change in condition was confirmed by the Nursing Home Administrator (NHA). This deficiency highlights the facility's failure to ensure proper documentation and communication regarding the resident's care needs.
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.
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What surveyors actually found near you
We read the 200 citations issued within 25 miles in the last 12 months — including the 3 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pottsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens At York Terrace, The | 0.2 mi | ★★★★★ | 0 | 0 |
| Edenbrook Of Greenwood Hill | 2.3 mi | ★★★★★ | 4 | 0 |
| Schuylkill Center | 2.9 mi | ★★★★★ | 16 | 0 |
| Rosewood Rehabilitation And Nursing Center | 4.2 mi | ★★★★★ | 1 | 0 |
| Seton Manor Nursing And Rehabilitation Center | 6.2 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.