Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marywood Heights during CMS and state inspections, most recent first.
A resident with significant mobility dependence and a care plan requiring 2 staff and a Hoyer lift for all transfers was transferred by a nurse aide without the required assistance or lift. The resident fell, developed a forehead hematoma, vomited after the fall, and hospital imaging showed a left clavicle fracture and a left first rib fracture. The DON confirmed the aide did not follow the care plan, substantiating neglect.
Two residents received antibiotic therapy for presumed UTI without documented clinical evidence meeting Revised McGeer Criteria. One resident with dementia, urinary retention, a history of cystitis, and a suprapubic tube had repeated urine testing and multiple antibiotic courses despite notes stating there were no signs or symptoms of infection and McGeer checklists showing criteria were not met. Another resident with stroke, diabetes, and overactive bladder had urine testing after odorous urine and increased incontinence, but an LPN documented that infection criteria were not met before an antibiotic course was ordered and administered.
Resident Council Grievance Not Fully Addressed: A resident group reported that snack service was inconsistent and that the issue had not been resolved, despite a grievance being marked resolved. The facility could not provide documented evidence that residents were satisfied with the outcome of the grievance or that concerns raised in Resident Council meetings and written grievances were fully communicated back to residents.
A resident with dementia and severe cognitive impairment was given Seroquel for behavioral disturbance without sufficient documentation that nonpharmacological interventions were tried or that underlying causes of the yelling were assessed. The record showed repeated yelling and verbal outbursts, a pharmacy recommendation for dose reduction, and no documented clinical rationale supporting continued use of the antipsychotic at survey exit.
Failure to update the care plan for a resident with anxiety, depression, and moderate cognitive impairment. Nursing notes and staff interviews showed ongoing accusatory behaviors about missed meds and missing belongings, and staff began using two staff members during care for reassurance, but the comprehensive care plan was not revised to reflect the resident’s current behavioral concerns, triggers, or individualized interventions.
A resident with a physician-ordered bowel regimen did not have the ordered protocol consistently followed when bowel tracking showed multiple consecutive days without a documented BM in Jan and Feb 2026. The MAR showed no documented evidence that nursing staff administered the ordered Milk of Magnesia, Dulcolax suppository, or Fleet enema during the identified periods, and the DON was unable to provide documentation that the bowel protocol was consistently followed.
Controlled Substance Documentation Discrepancies: A resident with a hx of atherosclerotic heart disease and dementia had orders for PRN Ativan, a Schedule IV controlled med. Review of the Master Controlled Substance Log and MAR showed multiple instances where lorazepam was documented as removed without MAR documentation of administration, and other instances where the MAR showed administration without a corresponding inventory removal entry. The DON was informed of the discrepancies during interview.
A facility failed to provide adequate supervision and safety measures for two residents, resulting in multiple falls and a serious burn. One resident, with hemiplegia and cognitive impairment, suffered a burn from hot soup due to lack of supervision during meals. Another resident, identified as a high fall risk, experienced repeated falls due to insufficient safety interventions and supervision. Interviews with the NHA and DON confirmed the facility's failure to implement necessary individualized measures.
A facility failed to ensure that an attending physician acted on a pharmacist's recommendations regarding a resident's drug regimen. The resident, diagnosed with multiple mental health disorders, was prescribed three anxiety medications. The pharmacist recommended a Gradual Dose Reduction (GDR) for Ativan and an evaluation of the medications to avoid duplication. However, there was no documentation of the physician's response to these recommendations, confirmed by the DON.
The facility failed to maintain accurate clinical records for three residents, including missing documentation of emergency room evaluations, tuberculosis screenings, and psychology appointments. This lack of documentation was confirmed by the facility's staff.
A facility failed to accurately document a resident's fall history in the MDS assessment. The resident, admitted with conditions including hemiplegia and anxiety, was at high risk for falls and had fallen prior to admission. However, the MDS assessment incorrectly indicated no falls in the month before admission.
A resident was admitted with several psychiatric disorders, and a diagnosis of bipolar disorder was added to their medical records without documented clinical findings to support it. Despite a physician's note suggesting bipolar depression and a change in medication, the comprehensive care plan was not updated to reflect a confirmed diagnosis. A later psychiatry consult diagnosed the resident with generalized anxiety disorder, and the DON confirmed the lack of documentation for bipolar disorder, indicating a deficiency in maintaining accurate medical records.
The facility failed to follow physician orders for two residents, resulting in deficiencies. One resident did not receive the prescribed bowel protocol despite not having a bowel movement for six days, with no evidence of medication administration or physician notification. Another resident was observed not wearing prescribed DARCO shoes, confirmed by staff and the resident, indicating non-compliance with the physician's order.
A facility failed to prevent urinary tract infections in a resident with an indwelling catheter. The resident's catheter was not changed as ordered, and there was no verification of irrigation specifics, leading to potential inaccuracies in urinary output documentation. Additionally, unsanitary storage of catheter supplies was observed, and duplicate orders resulted in improper documentation of catheter changes. The DON confirmed the facility's failure to provide appropriate care.
A resident with major depressive disorder exhibited consistent behavioral symptoms, but the facility failed to provide necessary psychiatric follow-ups. A scheduled appointment was canceled due to transportation issues and was not rescheduled, with no evidence of timely follow-up services. The NHA could not provide evidence of the resident receiving recommended psychological services.
A resident was administered Keflex for a possible UTI without clinical justification. Despite no signs or symptoms of a UTI and lack of diagnostic confirmation, the antibiotic was given from June 26 to July 5. The Infection Preventionist confirmed the administration was unjustified.
A facility failed to ensure a resident was free from unnecessary psychoactive drugs by not documenting a prescriber clinical rationale for Xanax use. A pharmacist's request for a gradual dose reduction was not addressed due to a miscommunication, and no evidence of a dose reduction attempt was found. This deficiency was confirmed by the NHA and DON.
Expired medications were found in a medication cart, with two multidose insulin vials labeled with an expiration date that had passed. An LPN confirmed the expired medications during an inspection, and the DON acknowledged that these should have been removed and discarded.
A facility failed to offer routine annual dental services to a Medicaid resident. The resident's care plan noted a decline of dental visits, but there was no documentation proving the resident was offered and declined services in the past year. The DON confirmed the oversight.
A facility failed to maintain infection control practices on a resident care unit. A resident with a urinary tract infection and an indwelling catheter had orders for daily irrigation. However, an undated syringe and an unlabeled bottle of sterile water were found in the resident's bathroom. Staff confirmed the items should have been labeled and dated, indicating a lapse in infection control.
Failure to Follow Required Transfer Assistance
Penalty
Summary
The facility failed to protect a resident from neglect by not providing transfers with the required assistance of two staff members and a mechanical lift as directed in the care plan. Resident 65 was admitted with diagnoses including need for assistance with personal care and generalized muscle weakness. The resident's annual MDS showed total dependence for bathing, maximum assistance for personal hygiene, dressing, toileting hygiene, bed mobility, and assistance lying down in bed, and dependence on staff for all transfers. The care plan, initiated in December 2025, required two staff members and a Hoyer lift for all transfers, and the task list also indicated the resident required assistance of two staff members for all care. On March 5, 2026, staff documented that Resident 65 fell from the bed and was observed with a hematoma to the left forehead. The resident vomited undigested food after the fall, and the physician ordered transfer to the hospital for further evaluation. The DON later documented that staff reported a witnessed fall at 8:58 PM, that the resident had a 2 cm by 2 cm raised hematoma to the left forehead, and that the resident was unable to verbally communicate pain due to aphasia but was observed holding the head and grimacing. The resident was also observed holding the stomach and vomiting a large amount of undigested food 10 minutes after the fall. The facility investigation included a written statement from a nurse aide who reported transferring Resident 65 from a recliner chair to the bed without the required second staff member or Hoyer lift. The nurse aide stated the resident was not wearing nonslip socks and slid to the floor after being lifted to a standing position. Hospital records showed imaging revealed a mildly displaced fracture of the left clavicle and an acute fracture of the left posterior first rib. The DON confirmed the investigation determined the nurse aide did not follow the care plan requiring two staff members and a Hoyer lift for transfers, substantiating neglect.
Unnecessary Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary antibiotic therapy when antibiotics were administered without documented clinical evidence supporting infection criteria. Facility policy required antibiotic use to be based on minimum clinical criteria for active infection using Revised McGeer Criteria, but the records for both residents showed antibiotics were given despite documentation that they did not meet those criteria. Resident 2 had diagnoses including dementia, urinary retention, history of cystitis, and a suprapubic tube. After the resident’s son requested urine testing, a urine culture was obtained and antibiotics were ordered for presumed UTI. A Revised McGeer Criteria checklist completed by an LPN indicated the resident did not meet criteria for infection, and an infection progress note later documented the PA reviewed the findings and stated the resident did not meet clinical criteria for infection, though antibiotics were continued because of a history of prior UTIs and the perceived benefit was documented as outweighing the risk. The record also showed additional antibiotic courses were ordered later for hematuria and repeat testing, with documentation again indicating no fever, no change in mental status, no urinary complaints, and no signs or symptoms of infection, while McGeer checklists continued to show the resident did not meet criteria. Resident 50 had diagnoses including stroke, diabetes, and overactive bladder. The resident was noted to have odorous urine and urinary incontinence consistent with baseline functioning, with increased urinary incontinence reported, and urine testing was ordered. A Revised McGeer Criteria checklist completed by an LPN indicated the resident did not meet clinical criteria supporting infection requiring antibiotics. Despite this, an antibiotic was later ordered for UTI, and the MAR showed the resident received the full course without documented clinical evidence meeting McGeer Criteria. The DON confirmed the findings during interview.
Resident Council Grievance Not Fully Addressed
Penalty
Summary
The facility failed to make reasonable efforts to address concerns raised by the Resident Council and failed to keep residents informed regarding the status and outcome of identified concerns. A review of the facility grievance policy showed that residents, families, and representatives had the right to voice grievances and that the grievance official would follow up on all concerns and grievances. Resident Council meeting minutes from December 29, 2025, documented resident concerns that snacks were not being provided daily, and a grievance was filed the same day. The grievance record showed that audits would be completed and that the grievance was signed as resolved on December 31, 2025. During a group meeting on March 25, 2026, five residents attending the Resident Council meeting, identified as Residents 31, 48, 30, 38, and 35, unanimously reported that the facility had not addressed their complaints about snacks. The residents stated that snacks were delivered for a while and then stopped, and that they did not feel the grievance had been resolved because the issue remained ongoing. The facility was unable to provide documented evidence that residents were satisfied with the outcome of the grievance, and the NHA also could not provide documented evidence of resident satisfaction in addressing grievances raised during Resident Council meetings and written grievances.
Chemical restraint used without adequate documentation
Penalty
Summary
The facility failed to ensure one resident was free from the use of a chemical restraint when Quetiapine Fumarate 25 mg daily at noon was ordered for dementia with behavioral disturbance without sufficient documentation of a medical symptom requiring the antipsychotic or evidence that less restrictive alternatives were attempted or clinically contraindicated. The resident had a history of dementia with behavioral disturbances and hypertension, and the admission MDS showed severe cognitive impairment with a BIMS score of 4. The clinical record documented repeated yelling behaviors, including notes that the resident periodically yelled out “help me,” that occasional verbal outbursts stopped when the resident’s daughter arrived, and multiple behavior monitoring entries in February and March showing yelling on several days and shifts. However, the record did not contain sufficient documentation that staff or the physician evaluated possible underlying causes of the yelling, such as pain, discomfort, environmental overstimulation, emotional distress, changes in routine, or need for social interaction or reassurance, before the antipsychotic was initiated. A pharmacy recommendation dated March 18, 2026, advised evaluation for a dose reduction within 14 days of initiation of the antipsychotic medication, but the physician disagreed and documented that a new order would follow. At survey exit, the record did not contain a new order or documented clinical rationale supporting continuation of the current Seroquel dose. Observations also showed the resident asleep in a Geri-chair and later appearing sleepy while being fed by staff. The DON reviewed the findings during interview and the report cited deficiencies related to medical director responsibilities, resident care policies, nursing services, use of restraints, and medical records.
Failure to Update Care Plan for Ongoing Accusatory Behaviors
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered comprehensive care plan for a resident with generalized anxiety and depression who was moderately cognitively impaired on the quarterly MDS. Although the resident’s record showed no behaviors related to rejection of care, wandering, physical behaviors, or verbal behaviors on the MDS, nursing progress notes documented ongoing behavioral concerns after admission, including accusations that medications were not given, concerns that other residents were entering the room and taking belongings, and statements that clothing items were missing. The record also showed staff responses to these concerns, including reviewing medications with the resident, obtaining a signed acknowledgement that medications were received, and communicating with the responsible party about missing clothing and laundry concerns. During observation, an LPN requested an RN supervisor to observe medication administration because staff had recently been accused of not administering medications and of taking the resident’s belongings, and the RN supervisor stated staff had begun providing care with two staff members present due to the resident’s ongoing accusatory statements. Review of the comprehensive care plan showed no revisions to address the resident’s ongoing behaviors, identify triggers, or include individualized interventions such as two staff members during care interactions.
Failure to Follow Physician-Ordered Bowel Regimen
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not following physician orders for a bowel regimen for one resident. The resident had orders dated July 19, 2024 for Milk of Magnesia 30 mL by mouth as needed if no bowel movement by day 3, Dulcolax suppository 10 mg as needed if no bowel movement by day 4, and Fleet enema as needed if no bowel movement by day 5, with notification of the MD if there was no result. Review of the bowel tracking record showed multiple periods in January 2026 when the resident had no documented bowel movement for several consecutive days, including January 18, 19, and 21 across all three shifts, January 20 and 22 on first and third shifts, and January 28 through 31. The Medication Administration Record for January 2026 showed no documented evidence that nursing staff administered the ordered bowel protocol during those periods of no bowel activity. In February 2026, the bowel tracking record again showed multiple consecutive days without a documented bowel movement, including February 2 through 5 and February 16 through 18 and February 21 through 23. The February 2026 MAR showed Milk of Magnesia was administered on February 6, 2026, corresponding to day 4 without a documented bowel movement, but there was no documented evidence that the remaining ordered bowel protocol interventions were given during the other identified periods. During an interview on March 25, 2026, the DON reviewed the findings and was unable to provide documented evidence that staff consistently followed the physician-ordered bowel protocol.
Controlled Substance Documentation Discrepancies
Penalty
Summary
The facility failed to maintain accurate controlled drug records and to ensure accurate documentation of medication administration for Resident 34. The resident was admitted with diagnoses including atherosclerotic heart disease and unspecified dementia. The clinical record showed physician orders for Ativan (lorazepam) 0.5 mg oral tablet, a Schedule IV controlled medication, first ordered every 6 hours as needed for agitation and later ordered every 4 hours as needed for restlessness and agitation. Facility policy required controlled substances to be tracked through a Master Controlled Substance Log, individual sign-off sheets, and shift-to-shift count reconciliation, with staff responsible for accurately documenting each dose removed and administered. A comparison of the Master Controlled Substance Log and the MAR for February 2026 through March 2026 showed six entries where lorazepam was removed according to the controlled substance log but there was no corresponding MAR documentation showing administration. The dates included February 11, February 13, February 19, March 1, March 3, and March 4. The same comparison also showed two MAR entries documenting lorazepam administration without corresponding documentation in the Master Controlled Substance Log showing the medication was removed from inventory on February 19 and February 27. During interview, the DON was informed of the discrepancies in the resident’s controlled substance documentation.
Inadequate Supervision Leads to Falls and Burn Injuries
Penalty
Summary
The facility failed to provide necessary supervision and implement effective individualized safety measures for two residents, leading to multiple falls and a serious burn. Resident 27, who was admitted with hemiplegia and hemiparesis, was severely cognitively impaired and required supervision during meals. Despite having a physician order for a Kennedy cup and other assistive devices, the resident accidentally spilled hot soup on himself, resulting in a burn. The incident occurred when staff placed the soup within reach and turned away to get an ice cube, failing to supervise the resident adequately. Resident 13, admitted with a history of hemiplegia, bipolar disorder, and anxiety, was identified as a high fall risk. Despite receiving transfer paperwork from a prior facility outlining necessary safety interventions, the facility did not timely implement these measures. The resident experienced multiple falls, some resulting in injuries, due to inadequate supervision and failure to maintain functioning alarms. The facility's inaction in addressing the resident's high fall risk and implementing sufficient safety measures led to repeated falls. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility's inability to demonstrate the implementation of necessary individualized fall prevention measures and sufficient staff supervision. The lack of adequate supervision and failure to adhere to safety protocols for both residents resulted in preventable injuries, highlighting deficiencies in the facility's care practices.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician acted upon the pharmacist's reports of irregularities in the drug regimen of a resident. The resident, who was admitted with diagnoses including major depressive disorder, anxiety disorder, obsessive-compulsive disorder, and dementia, was prescribed Ativan for anxiety. The consultant pharmacist recommended a Gradual Dose Reduction (GDR) of Ativan, as per CMS guidelines, unless clinically contraindicated. The pharmacist noted that if the drug therapy was to continue, the physician must document why the risk of adverse consequences from a GDR would exceed the benefits. However, there was no written documentation of the attending physician's response to this recommendation. Further reviews revealed that the resident was prescribed three medications for anxiety: Remeron, Ativan, and Buspar. The pharmacist recommended evaluating whether any of these medications could be reduced or discontinued to avoid duplication of effect. Despite a second request from the pharmacist, the facility failed to provide documentation of the attending physician's response or acknowledgment of these recommendations. An interview with the Director of Nursing confirmed the lack of documented evidence that the attending physician acted upon the pharmacy recommendations.
Deficiencies in Clinical Record Maintenance
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, as required by professional standards. Resident 13, who was admitted with conditions including hemiplegia and anxiety, was sent to the emergency room for dizziness and nausea after a fall. Upon return, there was no documented evidence of the emergency room evaluation or the treatment for a possible urinary tract infection, despite verbal instructions from the hospital to administer medication. Resident 37, diagnosed with Alzheimer's disease and hypertension, lacked documentation of tuberculosis screening in their clinical record, which is required by facility policy. Although the Infection Preventionist confirmed that screenings were conducted, they were not included in the resident's clinical record. This oversight was acknowledged by the Director of Nursing and the Nursing Home Administrator. Resident 60, with diagnoses including polyneuropathies and anxiety, had no documented evidence of attending a scheduled psychology appointment or a subsequent telehealth visit. The resident expressed frustration over the lack of support for the telehealth visit, which required family intervention to provide necessary equipment. The Director of Nursing confirmed the absence of documentation for these appointments and their outcomes.
Inaccurate MDS Assessment of Fall History
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the MDS assessment for a resident admitted with diagnoses including hemiplegia, hemiparesis, bipolar disorder, and anxiety did not accurately document the resident's fall history. The resident was identified as being at high risk for falls and had experienced a fall on May 24, 2024, prior to admission. However, the Admission MDS assessment incorrectly indicated that the resident had not fallen in the month prior to admission, as evidenced by the coded answer of 0 in Section J - Health Conditions, question J1700 Fall History on Admission/Entry or Reentry.
Failure to Document Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not properly identifying and documenting a resident's diagnosis of bipolar disorder. The resident, who was admitted with major depressive disorder, anxiety disorder, and obsessive-compulsive disorder, had a diagnosis of bipolar disorder added to their medical records on April 4, 2023. However, there was no documented evidence in the clinical record to support this diagnosis with clinical findings from the time of admission through the survey ending on July 25, 2024. A physician's progress note from April 30, 2023, indicated an impression of bipolar depression and a change in medication, but the comprehensive plan of care was not updated to reflect a confirmed diagnosis of bipolar disorder. Additionally, a psychiatry consult in October 2023 diagnosed the resident with generalized anxiety disorder, further complicating the clinical picture. The Director of Nursing confirmed the lack of documented evidence for a bipolar disorder diagnosis, highlighting a deficiency in maintaining accurate medical records according to professional standards.
Failure to Follow Physician Orders for Bowel Protocol and Therapeutic Shoes
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For one resident, the facility did not follow a prescribed bowel protocol despite the resident not having a bowel movement for six consecutive days. The clinical records showed no evidence that the necessary medications were administered, nor was there documentation of physician notification regarding the resident's condition. This oversight was confirmed during an interview with the Director of Nursing, who could not provide evidence that the bowel protocol was followed or that the physician was informed in a timely manner. In another case, the facility did not comply with a physician's order for the application of DARCO shoes for a resident. Observations over several days revealed that the resident was not wearing the prescribed shoes, instead opting for socks and sandals. Interviews with the resident and a licensed practical nurse confirmed the non-compliance with the physician's order. The Nursing Home Administrator and Director of Nursing acknowledged that the staff had not followed the order for the application of the DARCO shoes, as required.
Failure to Prevent Urinary Tract Infections in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including urinary retention and acute cystitis, had physician orders to change the catheter monthly and as needed for specific issues. However, the Treatment Administration Record for April 2024 did not show evidence of the catheter being changed as ordered. Additionally, orders from a urology appointment in May 2024 included daily irrigation of the catheter to prevent sediment buildup, but there was no evidence that the nursing staff verified the specifics of the irrigation process, such as the solution or amount to be used. This lack of verification potentially led to inaccurate documentation of the resident's urinary output. Further issues were noted in July 2024, when the resident pulled out the catheter, and a new one was inserted, but the change was not documented in the Treatment Administration Record. The catheter was documented as changed on two consecutive days later in July due to duplicate orders. Observations also revealed unsanitary storage of catheter irrigation supplies in the resident's bathroom. The Director of Nursing confirmed the facility's failure to provide appropriate care and services for the resident with recurring urinary tract infections.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to consistently provide necessary behavioral health services to meet the needs of a resident diagnosed with major depressive disorder. The resident, admitted with a history of depression, exhibited consistent behavioral symptoms of yelling out repeatedly, which were not easily redirectable. Despite having a care plan that included psychiatric follow-ups, the resident's scheduled appointment with a psychiatrist was canceled due to the facility's inability to provide transportation. This appointment was not rescheduled by the time of the survey, and there was no documented evidence of timely follow-up psychiatric services being provided. During an interview, the Nursing Home Administrator was unable to provide evidence that the resident received the recommended psychological or psychiatric services.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic drugs. Resident 13, who was admitted with diagnoses including hemiplegia, hemiparesis, bipolar disorder, and anxiety, was sent to the emergency room after a fall. Upon returning to the facility, the resident was prescribed Keflex for a possible urinary tract infection (UTI) without any acute injuries or confirmed diagnosis. The antibiotic therapy was initiated despite the absence of urinalysis results or signs and symptoms of a UTI. The facility continued administering the antibiotic from June 26, 2024, through July 5, 2024, without clinical justification, as confirmed by the Infection Preventionist. The hospital did not perform a culture and sensitivity test, and the urinalysis results did not support the diagnosis of a UTI. The nursing documentation during this period did not indicate any symptoms of a UTI, highlighting the unnecessary administration of the antibiotic.
Failure to Document Clinical Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychoactive drugs by not having a documented prescriber clinical rationale for the use of a psychotropic medication. Resident 45, who was admitted with a diagnosis of dementia, had a physician order for Xanax to manage anxiety. A pharmacist consult requested a gradual dose reduction (GDR) for the Xanax, but there was no physician response to this request. The consult was mistakenly sent to the wrong physician and had not been reviewed by the correct physician by the time of the survey. The facility could not provide evidence of a GDR attempt or justification for the continued use of the current Xanax dose over the past year. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to adhere to medication and pharmaceutical expiration dates, as observed in one of the four medication carts. During an inspection of the second-floor Cart A medication cart, two multidose insulin vials were found to be expired. Specifically, a vial of Lantus 100 units/mL and a vial of Admelog 100 units/mL were labeled with an expiration date of July 17, 2024, yet were still present in the cart on July 25, 2024. This observation was confirmed by a licensed practical nurse at the time of the inspection. An interview with the Director of Nursing further confirmed that these expired medications should have been removed and discarded from the medication cart. The failure to do so was a violation of the facility's obligation to ensure that all drugs and biologicals are stored and managed according to professional standards, as outlined in the relevant Pennsylvania Code sections.
Failure to Offer Routine Dental Services
Penalty
Summary
The facility failed to offer routine annual dental services to a resident whose payor source was Medicaid. The clinical record of the resident, who was admitted to the facility, showed no documented evidence that dental services had been offered in the past year. Although the resident's care plan indicated that they declined dental visits, the facility could not provide documentation proving that the resident was offered and declined dental services during the past year. An interview with the Director of Nursing confirmed that the facility had not offered the resident routine dental services in the past year.
Infection Control Lapse in Resident Care Unit
Penalty
Summary
The facility failed to maintain proper infection control practices on one of its resident care units. A clinical record review revealed that a resident was admitted with several diagnoses, including urinary retention, acute cystitis, and a urinary tract infection, necessitating the use of an indwelling catheter. Orders from a urology appointment required daily irrigation of the Foley catheter to prevent sediment buildup and changes every four weeks. However, during an observation, an undated bulb piston syringe and an unlabeled, opened bottle of sterile water were found in the resident's bathroom, indicating a lapse in infection control practices. Interviews with a licensed practical nurse and the Director of Nursing, in the presence of the Nursing Home Administrator, confirmed the observations. The staff acknowledged that the items should have been labeled and dated to prevent potential infection spread. The facility's failure to maintain resident care equipment properly was confirmed, highlighting a deficiency in infection prevention and control measures.
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 516 citations issued within 25 miles in the last 12 months — including the 6 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 Scranton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Ridge Care Center | 0.5 mi | ★★★★★ | 3 | 0 |
| Embassy Of Scranton | 1.7 mi | ★★★★★ | 24 | 1 |
| Dunmore Health Care Center | 1.8 mi | ★★★★★ | 6 | 0 |
| Allied Services Transitional Rehab Unit | 2.1 mi | ★★★★★ | 3 | 0 |
| Elan Skilled Nursing And Rehab, A Jewish Senior Li | 2.1 mi | ★★★★★ | 14 | 1 |
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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.